A Bright OutlookThe Eye Institute is opening exciting new prospects for people with impaired vision.
What if you opened your eyes one morning to find a dark spot in the center of your field of vision? Just a few years ago, there was not much doctors could do to keep you from losing much of your eyesight. But recently, a man from Wisconsin’s Fox River Valley found the outlook has changed dramatically.
Bob Locke, 87, of Appleton suffers from age-related macular degeneration (AMD), an eye disease that attacks central vision. While some people with AMD experience a sudden onset of symptoms, Bob did not even suspect a problem until five years ago, when an eye exam revealed early signs of the disease. For Bob, an illustrator who trained at the Art Institute of Chicago, the news was hard to take. Even in retirement, he continued to practice and enjoy his profession, and he used the income to supplement his Social Security and pension earnings. Seeking solutions, Bob made an appointment at the Eye Institute at Froedtert & the Medical College of Wisconsin.
New HopeThe Eye Institute is a world-class academic vision center that combines patient care with research and medical education. The Eye Institute opened in 1976, and has long been known as one of the nation’s preeminent centers for the care and study of vision disorders, including AMD. The director of the Eye Institute is Dale Heuer, MD, chairman of Ophthalmology at the Medical College of Wisconsin. According to Dr. Heuer, AMD is a disease of the retina, the sensitive inner lining at the back of the eyeball. It occurs when the macula, the part of the retina that enables you to perceive details, begins to deteriorate.
There are two forms of the disease. “Dry” AMD is caused by aging-related changes in the retina, and it normally results in a gradual decline in eyesight. “Wet” AMD occurs when abnormal blood vessels leak fluids under the macula, and it can lead to sudden vision loss. Bob Locke has wet AMD.
“It used to be that wet AMD was the death knell for the eye,” Dr. Heuer said. “Recently, though, there have been some big advances that offer hope of stabilizing or even reversing vision loss.”
At the Eye Institute, Bob saw Thomas Connor, Jr., MD, Medical College of Wisconsin ophthalmologist. Dr. Connor began by tracking Bob’s condition, which mainly affected his right eye. After about a year, Connor recommended a new laser treatment that was proving successful against wet AMD. Bob agreed to give it a try.
The treatment is called photodynamic therapy. During this procedure, a photo-sensitive medication is injected into the patient’s bloodstream through an IV. When the medication circulates to the retina, a physician uses a low-energy laser to “spotlight” abnormal blood vessels. The laser activates the medication, which seals the vessels and keeps them from leaking.
For Bob, the treatment was a success: “My right eye is now almost 20/20.” Unfortunately, at around this time, a black spot began to develop in his left eye. Dr. Connor recommended a change in tactics — an experimental drug called Lucentis.
Successful TrialAccording to Judy Kim, MD, a Medical College of Wisconsin ophthalmologist who specializes in diseases of the retina, pharmaceuticals are transforming the outlook for many vision-threatening diseases. “In the past, our principal options were surgery or laser treatment,” Dr. Kim said. “Now we are able to use drugs to modulate various eye diseases at the molecular level.”
Lucentis, approved by the FDA this summer, works by inhibiting a protein that leads to the growth of abnormal blood vessels. In clinical trials, more than 90 percent of patients who received Lucentis maintained their vision for two years and about one-third experienced improved vision. As a participant in the Lucentis trial, Bob received a dose every month. The drug is injected directly into the eyeball. “For a couple of days after each injection, I felt like shutting my eye all the time,” Bob said. Fortunately, the discomfort paid off. During two years of Lucentis therapy, Bob maintained his vision and even experienced a small degree of improvement. “My vision grew no worse and it got a bit better — the AMD stabilized.”
Dr. Kim believes the chance to take part in drug trials like these is a major benefit for patients at the Eye Institute. “The patient and the doctor become a team and we get to test some of these drugs before anyone else can offer them,” Dr. Kim said. “That puts us on the leading edge of the field.”
Perfecting TechniquesThe Eye Institute’s leading role in clinical research reflects the prominence of its medical staff. In all, 11 physicians at the Eye Institute have been named to the prestigious Best Doctors in America® 2006 list.
One of those doctors is Steven Koenig, MD, a Medical College of Wisconsin ophthalmologist who specializes in treating diseases of the cornea, the clear membrane at the front of the eye. Dr. Koenig is an expert in corneal transplantation.
“The innermost layer of the cornea is made up of special cells that keep the cornea clear, Dr. Koenig explained. “When that layer becomes damaged or unhealthy, the cornea becomes cloudy.” The traditional approach to treating this condition is to remove and replace the entire cornea. The problem with this approach, according to Dr. Koenig, is that it requires 16 stitches and often takes more than a year to heal. “Also, the transplanted cornea often ends up warped — more like a football than a basketball – which can cause severe astigmatism.”
A new approach to cornea transplant is called deep lamellar endothelial keratoplasty (DLEK). Developed by a Dutch physician, DLEK leaves most of the patient’s own cornea intact. “In the DLEK procedure, we remove and replace just the diseased inner layer of the cornea,” Dr. Koenig said. “The beauty is that we can usually close with only one stitch, the patient’s vision recovers very rapidly (usually stable within one month) and there is no astigmatism.”
About 40,000 Americans have a cornea transplant every year, and Dr. Koenig believes most of them could benefit from DLEK. Recently, he became one of the first surgeons in the United States to offer this specialized corneal surgery.
Vision ResearchWhile Dr. Koenig and others refine clinical techniques, another group within the Eye Institute is concentrating on “basic science” research. Over the last two years, this group of Medical College of Wisconsin researchers has doubled in size, adding three new investigators.
One of the newest members of the research team is Joseph Carroll, PhD. Dr. Carroll’s area of focus is adaptive optics, a Cold War imaging technology that has recently been applied to ophthalmology.
“Stars appear to twinkle, but of course they don’t really — what you’re actually seeing is the effect of starlight passing through the turbulence of the atmosphere,” Dr. Carroll explained. “Just like the atmosphere, the human eye is loaded with aberrations that degrade the light passing through.” That makes it difficult for physicians to obtain a good image of the retina. “Using current clinical imaging devices, you can get a look at gross retinal features, but can’t visualize the retina on a cellular level.”
The term “adaptive optics” refers to using an optical device (usually a flexible mirror) to compensate for the eye’s aberrations. “This technology allows us to obtain high-resolution images of the retina — enabling us to see structures smaller than the thickness of a human hair.”
While these imaging devices haven’t made their way into the doctor’s office, Dr. Carroll says that this sort of imaging can lead to better diagnosis and treatment of retinal disease. “The idea is that by the time someone comes in and says ‘I can’t see,’ it’s often too late. The ability to see the retina on a cellular level could allow doctors to diagnose earlier (and preemptively treat) a number of blinding diseases.”
Complete Eye CareJoseph Carroll’s work underscores the importance of discovering novel approaches to vision diagnostics. One advanced option now available at the Eye Institute is multifocal Electroretinography (mfERG), a test that measures how well rod and cone cells function at different points in the retina. According to Dennis Han, MD, Medical College of Wisconsin ophthalmologist, mfERG allows physicians to diagnose unusual genetic conditions that previously caused unexplained vision loss. It also helps detect early signs of damage caused by certain prescription drugs. The diagnostic technologies available at the Eye Institute support a full range of specialty services. In addition to retina and cornea/external eye diseases, the Institute’s 18 Medical College of Wisconsin physicians provide expertise in glaucoma, ocular oncology, oculoplastic surgery, neuroophthalmology, refractive surgery, vision rehabilitation and pediatric ophthalmology.
The Institute also provides emergency trauma care, and physicians perform about 200 surgeries per month in the Institute’s four operating rooms. Another organization-wide focus is educating new doctors. Currently, the Eye Institute’s program includes nine residents, as well as three fellows receiving advanced training.
In July, the Eye Institute opened a new clinic in Pewaukee. Known as Eye Institute - West, the clinic offers appointments four afternoons a week for patients with retinal disease and children who need special vision care.
One-Stop ShoppingAccording to Stephen Alper, PhD, administrative director, what sets the Eye Institute apart is its multidisciplinary environment: “We offer state-of-the-art care, conduct clinical and basic science research and train future doctors — all in the same building,” Alper said. Dr. Heuer believes this cooperative environment is good for patients, especially those with complex eye disease. “We offer one-stop shopping for people with extremely complicated eye problems — multidisciplinary problems that require two, three, maybe four different specialists.”
Medical College of Wisconsin researchers find the environment especially positive. “We go to the clinical group for patients to work with, and the clinicians often come to us to see what we are doing,” Dr. Carroll said. “The atmosphere couldn’t be better in terms of making headway on understanding and treating eye disease.”
Back to the Drawing BoardThanks to the treatment he received at the Froedtert & the Medical College Eye Institute, AMD has not prevented Bob Locke from living a normal life — or kept him away from the drawing board. “I enjoy doing my work,” he said. “It keeps me busy, keeps the mind going, because you can’t sit and watch TV all the time.”
Bob is grateful to the people of the Eye Institute. “Everyone here is very good and caring,” he said. “And Dr. Connor is outstanding, personally and as a caregiver. He is thoughtful, considerate and highly skilled.”
For the staff at the Eye Institute, gratitude goes both ways. “We work with everyone from babies who are 15 weeks premature to people beyond age 100,” Dr. Kim said. “They all have a story, and that’s the gratifying thing about working in this field.”
“Vision is so important to people, and being able to restore or preserve their vision so their lives can go on is a true privilege.”
Source: Froedtert Today
Date: September 2006