Aging Eye Diseases - Are we prepared to handle the epidemic?

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Aging Eye Diseases - Are we prepared to handle the epidemic?

Sandeep Jain, MD

Sat Jun 16 07:51:05 -0700 2007

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The leading causes of vision impairment and blindness worldwide are primarily age related eye diseases - macular degeneration, glaucoma and cataract . The number of individuals with age-related eye disease is expected to double within the next three decades. Technological innovations will be needed to improve the quality of life of people with aging eye diseases. The Eye Digest, published by the University of Illinois Eye & Ear Infirmary is spearheading technological innovations in vision health dissemination with the goal of stimulating a debate that influences public policy on dealing with the epidemic of aging eye diseases.

The leading causes of vision impairment and blindness in the United States are primarily age-related eye diseases. The number of Americans at risk for age-related eye diseases is increasing as the baby-boomer generation ages. These conditions, including age-related macular degeneration, cataract, diabetic retinopathy and glaucoma, affect more Americans than ever before. With the aging of the population, the number of Americans with major eye diseases is increasing, and vision loss is becoming a major public health problem. By the year 2020, the number of people who are blind or have low vision is projected to increase substantially.

Blindness or low vision affects 3.3 million Americans age 40 and over, or one in 28. This figure is projected to reach 5.5 million by the year 2020. The study reports that low vision and blindness increase significantly with age, particularly in people over age 65. People 80 years of age and older currently make up eight percent of the population, but account for 69 percent of blindness.

The critical barriers to helping visually impaired older Americans attain independence and a better quality of life range from the pervasive assumption that vision (as well as other physical abilities) and personal autonomy “naturally” are lost as one grows older, to the fragmented way in which treatment tends to be delivered after diagnosis of an eye disease, and to the traditional approaches of researching and treating eye disease. Without question, medical, surgical, and technological progress in understanding and treating many aging eye diseases has improved the ability to preserve vision and/or slow down loss of vision. This progress, combined with advances in and the increasing use of low vision aids has helped many visually impaired older persons, but these approaches have not yet fostered the quality or degree of self reliance for the elderly that they desire and that should be possible. Assumptions at the individual, societal, public policy and medical levels that any improvement in vision is a benefit must be overcome in order to produce greater personal freedom and independence for low vision older adults.

Vision research predominantly is conducted in distinct domains, creating additional barriers to implementing approaches that will increase independence among visually impaired older Americans. Research in the area of vision rehabilitation tends to be aimed at improving rehabilitation techniques or improving delivery of and/or access to vision rehabilitation services. Clinical research and treatment in of aging eye diseases such as macular degeneration or glaucoma aim for less loss of vision as the "vision benefit" rather than improvement in vision or cure of the underlying disease. Basic vision science research focuses on the pathology of individual diseases and/or structural components of the eye such as the cornea and surface eye disease or retinal diseases. As in other areas of basic biomedical research, vision science discoveries about causal or contributing factors to vision loss resulting from eye disease may not be translated as quickly as possible to clinical applications because of the prevailing model in which basic science tends to be conducted – that is, by individual investigators pursuing research questions that push the boundaries of what is proven and known in their immediate area of interest to generate new understanding and knowledge of that topic. The paradigmatic limitations of the established ways to conduct basic science research, including the system of rewards adopted by academic research centers and funding agencies, tend to keep information within individual disciplines. As a result, research findings on aging eye diseases by and large is conducted, published and consumed within the scientific community working in the same area. This emphasis on specialized knowledge has numerous negative consequences for advancing the translational research that will foster independence for low vision elderly. First, dissemination of vision science research findings to geriatric researchers, or the reverse, happens infrequently, with few incentives to encourage meaningful interdisciplinary exchange. Thus, the basic scientists with potentially the greatest to offer in terms of discovering the means to stopping a disease process remain focused in their narrow disciplinary specialization. Second, young scientists, like those who have preceded them, will pursue research careers in the highly specialized disciplines; similarly, young clinicians tend to go into established surgical and clinical subspecialties. While the established system of rewards in both the clinical and research domains reinforces specialization, it creates sizeable barriers to examining and pursuing scientific and medical problems from a broad perspective such as aging eye research and geriatric ophthalmology. Young researchers and physicians starting their careers today will not find many mentors and role models in these areas.

A related problem is that communication about basic vision research tends to remain within highly defined disciplinary boundaries, making it difficult for the nonscientific community to access this information. Despite the availability of web-based sources of information on vision research findings, this information will remain among scientists and clinicians unless it is translated into language accessible to policy makers, businesses and the interested public. Public policy debate, including decisions about funding, will not benefit from new research unless that research is communicated in a way that the nonscientific community can readily consume and easily understand.

The barriers described above are not insurmountable. Emerging technologies have the potential to supplant the present manner of diagnosing, treating and assisting older patients with low vision, especially if they are harnessed with the primary objective of improving independence for aged low vision patients. For example, sustained drug release using nano-particles may change the existing paradigm of clinical practice. Research resources can be dedicated specifically to the development of animal models of aging eye disease, accelerating the translation of basic vision science to clinical applications. Computer programs can be written to optimize viewing by visually impaired older patients. The paucity of role models and mentors in aging eye research or geriatric ophthalmology can be directly addressed through a program that provides faculty advisors from both areas who are committed to translational science and offers structured pedagogic immersion in the methodologies of basic and clinical science, geriatric medicine, gerontology and epidemiology. More challenging are knowledge barriers. Yet, these too can be overcome through the design, implementation and continued employment of novel intellectual concepts that cross traditional disciplinary barriers within and between vision science, ophthalmology and geriatric medicine, identify and support translational methodological approaches, and apply innovations in technology and research tools that address the needs of low vision older Americans. Rather than approach translational research by seeking clinical applications for basic research findings that exist, a more effective approach may be to identify the clinical needs of elderly patients with low vision and increased dependency and steer basic science to address these needs. Just as the paradigm of basic scientific research and discovery with its emphasis on disciplinary specialization has failed to satisfactorily advance research toward clinical applications, traditional hierarchical organizational models will not produce the dynamic leadership needed to ensure a successful organization focused on aging eye disease and attainment of independence. Creating a paradigm shift in the conduct of basic vision research requires an enabling and supportive environment, an incentive system that encourages translational research, and the incorporation of geriatric medicine into vision science. Further, research resources must be created that that support high impact translational studies aimed at increasing the personal autonomy of elderly low vision patients by curing disease, providing diagnostic tools, and developing the next generation low vision aids.

(This article has been approved for publication by The Eye digest)

Aging Eye Diseases - Are we prepared to handle the epidemic?

Richard.Neal

Sat Jun 16 16:49:10 -0700 2007
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Fighting degenerative diseases is starting become new battle field in medicine and I hold allot of respect researchers in this field because they are fighting nature itself. As they say, we may be the last generation to die of old age or the first to live forever.

Aging Eye Diseases - Are we prepared to handle the epidemic?

Richard.Neal

Sat Jun 16 16:53:00 -0700 2007
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Argh! Clicked on the wrong button ..

Fighting degenerative diseases is starting become the new battle field in medicine and I hold allot of respect for the researchers as they are fighting nature itself. As they say, we may be the last generation to die of old age or the first to live forever.

Aging Eye Diseases - Are we prepared to handle the epidemic?

President4242

Mon Jun 18 09:20:46 -0700 2007
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the first to live forever.

Speaking as a member of the generation immediately following the baby boomers- I sincerely hope NOT. Our entire economic system is currently designed on having 5 workers for every retired person; it's failing because due to abortion we have only 2 workers for every retired person.

Imagine a world where there is only .0000001 worker for each retrired individual.....

Aging Eye Diseases - Are we prepared to handle the epidemic?

Gartogg

Sat Jun 16 22:33:21 -0700 2007
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The article bemoans the current system for addressing general health problems without proposing a better system; isn't a publication like "The Eye Digest" supposed to address issues like educating those in different specialties or the lay public about the various issues and problems in eye health, instead of bemoaning the fact that nobody addresses them? If it is an Eye-problem, who else would address it?

On the other hand, it seems a bit silly to talk about 2.2 million extra people over 40 with eye problems, when the population as a whole is growing older. Is there a demographic shift, or is this more specific? If it is demopgraphic, it seems that the increase is being overstated here, and addressed incorrectly. This seems to be the real issue, and if so, this isn't an eye health problem, it is a general health question specifically for the elderly. If people live longer, they will suffer more from diseases affecting the elderly - and gerontologists generally could address the problem. Maybe the issue could be addressed there, if that is the correct framework, instead of as an eye specific problem.

Aging Eye Diseases - Are we prepared to handle the epidemic?

Sandeep Jain, MD

Sun Jun 17 04:55:22 -0700 2007
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David,

The US Census Bureau estimates that the number of people more than 65 years of age in the US will more than double by the year 2050. People are living longer. Eye diseases, like macular degeneration, are not merely a result of the aging process. We are beginning to understand the pathogenesis and it seems that genetically determined inflammatory factors and unknown angiogenic dysregulation are important factors. I do not think one specialty, be it gerontology or ophthalmology is adequately equipped to deal with the disabilities that we foresee. This is the whole point of our article. We are making a case for a paradigm shift for dealing with aging eye disability - where research is 'goal' driven as opposed to traditional "hypothesis" driven. The goal has to be to increase the independence of people so that the quality of life improves. Also we are asking that the treatment approach has to be "interdisciplinary". We are proposing the creation of an aging eye center of excellence in the US to take a leadership role in addressing these issues. None of this is possible without a public debate and support. We are taking the first steps of educating the public.

Aging Eye Diseases - Are we prepared to handle the epidemic?

Ian Bierley

Mon Jun 18 16:14:47 -0700 2007
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Epidemic could well be the best way to describe the situation as it develops. Try call your local optometrist and mention the term "low vision", many are unfamiliar with the terminology and at best will refer you on to someone else. Once an individual is diagnosed with MD, RP or Glaucoma they are sent off on a long and winding route and somewhere down the line they may come across the defacto standard vision aid device, an expensive CCTV. The thing that we find sad is that visually impaired persons have almost no where to go to find out the options that are available to them. Not only are they confronted with the challenges of vision loss, they are actively mislead by various organizations or individuals who place their own commercial interests above the well being of the 'patient'.

As you may tell, as a manufacturer in this field, I am not approaching this from a medical perspective but rather as an advocate of rights for persons with visual impairment. Hopefully medicine will provide a solution, but in the meantime we have a growing epidemic in main stream society.