00:00welcome to the huberman Lab podcast
00:01where we discuss science and
00:03science-based tools for everyday life
00:08I'm Andrew huberman and I'm a professor
00:10of neurobiology and Ophthalmology at
00:13Stanford School of Medicine
00:15today my guest is Dr Jeffrey Goldberg Dr
00:17Jeffrey Goldberg is the chair of the
00:19Department of Ophthalmology at Stanford
00:21University School of Medicine he is a
00:23clinician and MD or medical doctor who
00:26sees patients every week as well as a
00:28PhD meaning a laboratory scientist who
00:31directs his own laboratory focused at
00:32understanding the mechanisms and cures
00:35for diseases of the eye Envision such as
00:37glaucoma retinitis Pigmentosa and
00:40macular degeneration indeed Dr Goldberg
00:42is one of the world leaders in
00:44developing methods to cure blindness he
00:46is also intensely knowledgeable about
00:49all things related to Vision so during
00:51today's discussion we indeed cover most
00:54all of visual and Eye Health you will
00:57learn for instance about the benefits as
00:59well as drawbacks of wearing corrective
01:02lenses such as contact lenses or
01:04eyeglasses for reading you will learn
01:06about the benefits and detriments of
01:09sunlight meaning how it can help your
01:12vision in fact how it can help reverse
01:14or prevent my own Opia nearsightedness
01:16as well as the things to be cautious
01:18about with respect to sunlight in terms
01:20of development of cataracts which are
01:23occlusions that prevent Vision we also
01:25discuss many tools for maintaining and
01:27improving Vision across the lifespan
01:29ranging from behavioral tools so
01:31specific Vision tasks and exercises for
01:34the eye that you can do that are known
01:36to improve or maintain your vision as
01:38well as specific surgical procedures
01:40such as LASIK surgery we get into all
01:43the details of for instance how often to
01:45do these various eye exercises how long
01:48the benefits are maintained as well as
01:50age-related considerations for things
01:52like Lasik eye surgery we even get into
01:54how to best clean your contact lenses
01:57whether or not to use disposable contact
01:59lenses or other forms of contact lenses
02:01we also discuss things like dry eye and
02:03the best remedies for dry eye and we
02:06talk about the scientific and clinical
02:07data around nutritional approaches and
02:10supplementation-based approaches for
02:12maintaining and improving Vision so
02:13whether or not you suffer from floaters
02:15or dry eye or you're considering
02:17changing your eye prescription or you
02:19have concerns about whether or not
02:20relying on corrective lenses is
02:22impairing your vision and you want to
02:24enhance your vision or if you're
02:26somebody who has perfect vision today's
02:28episode is going to include science and
02:30protocols that will be highly relevant
02:32to you I should also add that if you are
02:34somebody who suffers from or who has
02:36family members who suffer from diseases
02:37of the eye that can impact Vision such
02:40as glaucoma retinitis Pigmentosa and
02:42macular degeneration we also delve deep
02:45into the discussion about the most
02:47Advanced Technologies for preventing and
02:49offsetting vision loss due to those
02:51diseases as well thanks to Dr Goldberg's
02:54incredible knowledge his Clarity of
02:56communication and his generosity with
02:58that knowledge by the end of today's
03:00episode You Will Be armed with all of
03:02the modern information you need in order
03:04to best maintain and improve your eye
03:07and vision health before we begin I'd
03:09like to emphasize that this podcast is
03:11separate from my teaching and research
03:13roles at Stanford it is however part of
03:15my desire and effort to bring zero cost
03:17to Consumer information about science
03:18and science related tools to the general
03:20public in keeping with that theme I'd
03:23like to thank the sponsors of today's
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06:26now for my discussion with Dr Jeffrey
06:28Goldberg Dr Jeffrey Goldberg welcome
06:31thanks it's great to be here you and I
06:35we will spare people the discussion
06:37about all of that but
06:40I'm really excited for today's
06:41discussion because I get a tremendous
06:43number of questions about vision and Eye
06:45Health and of course as a neuroscientist
06:47who has worked on the visual system I
06:49sometimes have answers or partial
06:51answers but more often than not I don't
06:55and yet I'm confident that you do or
06:57that if you don't you can direct us to
06:59the proper place to get those answers so
07:01to kick things off I want to ask you
07:03what was one of the most commonly asked
07:05questions when I solicited for questions
07:08in anticipation of this episode which is
07:10how early should one do an eye exam on
07:14their child and how regularly should we
07:18all be doing eye exams
07:21is the fact that I think I can see
07:23normally confirmation that I can see as
07:26well as I think I can so that's really
07:28three questions but baby comes out do
07:31they check their eyes right away and if
07:32so how and how often should they check
07:34and what kind of information is there
07:36yeah it's as a great question it's
07:39obviously something that touches us all
07:41so the the answer that really differs a
07:44little bit uh at the different stages of
07:45Life first of all every every baby gets
07:49an eye exam or should be getting an eye
07:50exam and uh one of the main things that
07:53you really just are screening for right
07:55when that baby is born right in the
07:57nursery right in those first few days is
08:00to just look for a red reflex you know
08:01when you take a camera picture a Flash
08:03picture and sometimes you get red eye
08:05that's actually the light from the flash
08:07as you know reflecting against the
08:08retina coming back out of your eye it
08:13um and a red reflex is actually very
08:15normal that's that that's great and if
08:17you have a one of a number of
08:20diseases in the eye that can present
08:22even in babies even in newborn babies
08:25including most concerning but thankfully
08:29least common retinoblastoma which is the
08:31most common pediatric eye cancer which
08:35again thankfully is quite rare uh those
08:38babies won't have a red reflex in that
08:40eye it'll be kind of a whitish or gray
08:42reflex and so even just that first
08:45little you know doctor's taking the
08:47little pen light and even just flashing
08:48it in that's in the baby's eyes so
08:50that's that's that's our first eye exam
08:52and hopefully we've all had that and
08:54hopefully every baby being born today is
08:56getting that getting that first eye exam
08:58is really just looking for that red
09:01uh it's not typical as long as that's
09:05um to worry about getting an eye exam
09:08from there kind of through
09:11um childhood like maybe early Elementary
09:13School unless they your baby is
09:16presenting with one of a number of
09:18features that parents often pick up on
09:20for example as the baby's aging through
09:23those first couple of years you know
09:24through the first couple of years babies
09:26actually don't have great visual Acuity
09:28and so as they're aging over those first
09:31couple years it's normal for them to
09:33have you know roving eye movements for
09:36example be searching their environment
09:38but over those first couple of years if
09:41parents start noticing the baby isn't
09:43you know isn't uh making eye contact or
09:46looking where a sound is certainly if
09:49they have what's called nystagmus like
09:50these rapid flickering alternating eye
09:52movements uh anything like that of
09:55course you're going to trigger trigger
09:56an eye exam but otherwise most babies
09:58other than their pediatrician doing that
10:01red reflex check when they're in for
10:03their regular well child checks uh
10:05that's really all that's uh needed
10:07through that when most kids get to
10:09elementary school age there will often
10:11be often done at the schools and
10:14amblyopia screening exam if kids eyes
10:18either if one eye doesn't see that well
10:20like maybe you're very nearsighted or
10:22farsighted in one eye and pretty normal
10:24sighted in the other or the two
10:26refractive errors are quite different
10:28from each other that can lead to a
10:31condition you've talked about on the
10:33podcast before called amblyopia which is
10:36probably one of the more common or most
10:37common eye diseases of children
10:41or if the eyes are in a line you know
10:43our eye muscles and the Brain behind
10:45them are really responsible for keeping
10:46the two eyes looking straight ahead and
10:49if that's not working properly and one
10:51eye is is off kilter and therefore the
10:54image of what we're looking at is
10:56falling on different spots of the retina
10:57it's not sinking upright in the brain
10:59that can lead to this disease condition
11:01called amblyopia where that eye is no
11:04longer talking to the brain properly and
11:06there's a pretty easy screening exam
11:08that can be done for strabismus the
11:10misalignment of the eyes that kids will
11:12do in elementary school the other main
11:14presenting symptom of kids in elementary
11:16school is when they admit to their
11:18parents I can't see the board or I can't
11:20see the teacher up front and then they
11:22might be quite nearsighted and so that
11:24will also trigger an exam and so those
11:27are usually the parts for for babies for
11:29toddlers for children school-aged
11:31children that might reasonably trigger
11:33an exam a couple of questions about
11:35early eye exams and we'll um get on to
11:39uh eye exams in older visuals in a
11:41second but I want to interrupt you with
11:43this question so you mentioned that um
11:45you know there can be a misalignment of
11:47the eyes I've seen many people's babies
11:49where there is one eyeball that seems to
11:51be kind of drifting around and then it
11:52might correct but sometimes they'll have
11:54a we don't want to get technical here
11:56for our listeners we'll keep it General
11:58but either convergent eyes or one eye
12:01converging cross eyes or walleyed you
12:04know again using uh that non-technical
12:08um and my understanding is that the
12:11brain is taking that information in and
12:13it's very plastic it's changing at these
12:15early stages of development and that
12:16it's fairly critical to get that stuff
12:19corrected early on because if you wait
12:21too long the brain can essentially
12:22become blind to the the um or rather the
12:26the brain cannot learn to handle the
12:29proper alignment so in other words if a
12:33crossed eyes excuse me and they're not
12:36corrected uh until their 20s it's
12:39possible that they will never recover
12:40normal vision whereas if you recover if
12:42you align the eyes properly early in
12:44development they can indeed recover
12:47Vision how early can and should one
12:50consider getting those eye realignments
12:52done yeah yeah pretty much right on what
12:55they'll do is if they detect any eye
12:57misalignment and sometimes parents are
12:58are good at noticing that and sometimes
13:01you take a picture and one eye got the
13:03red eye reflex and the other one didn't
13:05and sometimes people notice that their
13:07kids eyes are sort of turning in it
13:11um sometimes there's what's called
13:13pseudostrabismus which is where actually
13:15depending on your Anatomy if you have a
13:16little extra skin sort of on the inside
13:19corners of your eyes it makes your eyes
13:20look turned in when actually they're
13:22straight but if your eyes are actually
13:25turned in or slightly less common in
13:27children more common in adults
13:29misalignment turned out
13:31it's really important to correct that
13:33early and the reason is as you were
13:35saying the brain starts ignoring it it
13:39fails to fully develop the straw wrong
13:41connections from the for the data coming
13:44in from one of those two eyes into the
13:47brain and if you pass certain sort of
13:49thresholds during development during
13:51childhood without correcting that
13:54connectivity getting those two eyes to
13:56work together properly you can
13:59permanently lose that
14:01um and so we use sort of we used to use
14:05very sort of uh you know gross numbers
14:07like it's fully correctable if you can
14:09intervene before age three it's partly
14:11correctable if you can intervene before
14:13age six you got a chance before age nine
14:17but it turns out in follow-on studies
14:19that even kids into their young teens
14:22have a shot at correcting that I brain
14:25connection that amblyopia that that loss
14:28of vision uh that that can occur during
14:30early development so even if you're only
14:33you know unfortunately detecting that
14:36later on in childhood or even sort of
14:38the tween years or early teen years it's
14:41still worth a try to really push to
14:44um retrain the weaker eye and then also
14:48realign the muscles so that they can
14:51work together to keep the eyes focused
14:53I'll tell you it's interesting and
14:55there's a lot more to learn about brain
14:57plasticity and probably a lot of really
15:01therapies yet to discover that could
15:03reopen what's called critical period
15:05plasticity this this this plasticity
15:08that we have during development that
15:09kind of goes away as we age and and that
15:12critical period plasticity as you know
15:13has been the best studied actually in
15:15the visual system and the idea that we
15:18could reopen that is really fantastic
15:20but for different parts of that ibrain
15:23connection there's different periods for
15:27critical period plasticity for example
15:28even if you get the amblyopic eye to see
15:32well again and then you realign the eyes
15:34and now they're working together a lot
15:36of kids will never recover full depth
15:39perception stereopsis the use of two
15:42eyes to see depth for example so why
15:45that part of the brain doesn't
15:47correct as well as the visual Acuity or
15:50central vision part of the brain I'm not
15:52sure if we understand that yet
15:54I'm going to ask for a curbside consult
15:57as sometimes called right now by telling
15:59you a story when I was a kid I went
16:01swimming without goggles and I had one
16:03eye closed and the other eye open and
16:06closing as it went in and out of the
16:07water because I'm a deficient swimmer
16:09and I only breathe to one side
16:12unless I really consciously forced
16:13myself to breathe to both sides in a
16:15freestyle swim got out of the pool and I
16:19it was pretty eerie and then it became
16:22downright scary because I didn't recover
16:24my double vision until they patched one
16:26of the eyes to forcing me to use the
16:29other eye that had been closed the
16:32and fortunately this was done early
16:35enough and it I was young enough that
16:37within I think it was about a day or so
16:39I restored what normal vision however my
16:43depth perception is terrible
16:46um I'm the kid that you know Fly ball
16:48was hit to me in the Outfield and it's
16:50coming it's coming and then it hit me
16:51this is why I've generally focused on
16:53foot Sports throughout my entire life as
16:55opposed to you know precise hand-eye
16:57coordination I'm better at throwing
16:58darts and things with one eye closed
17:00than I ever would be with both eyes
17:01maybe that's true for most people
17:06is it true that even just a few hours of
17:09misalignment of information to the two
17:12eyes early in development can
17:13permanently rewire the brain unless
17:16there are some corrective measures such
17:18as patching up one eye and the example I
17:21gave is just one but for instance if um
17:23uh you know someone injures you know
17:26gives a scratch on their cornea and they
17:28close they patch the eye and the person
17:29happens to be 10 years old is it
17:31important to then patch the other
17:33healthy eye after the the um you know
17:36the scratched eye is feeling better in
17:38other words how critical is it to ensure
17:40the balance of information coming into
17:43the two eyes even on the order of hours
17:45or days yeah your story is uh it has
17:49some features of uh you know totally
17:51usual how we think about misaligned eyes
17:54leading to amblyopia where one eye is
17:56weaker patching the strong eye so the
17:59weak eye can recover but not necessarily
18:01fully regaining depth perception and so
18:04that part of it is you know quite
18:07stereotypical the part of your story
18:09that's atypical is that for most kids
18:13um an hour to let alone minutes an hour
18:16to even an hour to a day if you were I
18:20don't know if you were a young kid and
18:21you just really were training up on
18:23throwing darts and you were just keeping
18:25one eye closed to throw the darts you
18:27know really practicing for an hour a day
18:28it'd be very unusual for that to trigger
18:32this kind of either strabismus
18:35misalignment of the eyes let alone
18:36amblyopia and the strabismus is what's
18:39giving you the double vision because
18:40they're misaligned let alone the
18:42amblyopia of one eye turning out weaker
18:44if I had to guess of course not having
18:47you know done your exam before that
18:49fateful day in the swimming pool if I
18:51had to guess I would guess that you may
18:53have had some intermittent business and
18:57your brain was already getting kind of
19:00and and you neither you nor your parents
19:02may have even noticed it it could be
19:04happening you know at other times a day
19:06or you're not kind of really paying
19:07attention it doesn't kind of stand out
19:09in the way that that that day that you
19:12got out of the swimming pool you really
19:13noticed it and it may not have been that
19:15strong it may have been quite
19:15intermittent but if you had had some
19:18years of intermittent isotropia or
19:20turning in of the eyes or exotropia
19:23turning out of the eyes that just
19:25happened here and there but was
19:26accumulating sort of uh damage or
19:30failure to connect over years leading up
19:32to that day in the swimming pool and
19:34that day just tipped you over the edge
19:36and you've got double vision you really
19:37noticed it that led to an eye exam and
19:40an eye care provider and they said wait
19:42a second this size stronger this size
19:43weaker you've got a little amblyopia
19:45we're going to start patching your
19:47strong eyes so you can get your weak eye
19:48back so for 99.9 percent of the kids who
19:51like you know yeah they get a little
19:53corneal scratch or they're patching one
19:55eye closed or or uh you know anything
19:59that's sort of a rare event like that
20:01nothing to worry about parents don't
20:03have to worry kids can be kids they can
20:05play they can do that kind of thing and
20:07uh and not have to worry and and it's
20:09unfortunate that we can't tell in
20:12which kid's been having the intermittent
20:14amblyopia because we don't do a standard
20:16eye exam on every five-year-old who's
20:18not complaining of anything but but yeah
20:21so that's a that's an unusual case in
20:23yours and if I had to guess I I would
20:24bet that you were having some sort of
20:27subclinical untracked Uncharted
20:30unnoticed maybe strabismus leading up to
20:33that point okay great thank you you can
20:36send me a bill at the end
20:40I'm 47 years old so I was part of the
20:44generation that grew up with some
20:45computers in the classroom but not a lot
20:49kids from a very young age are looking
20:53phones and screens and things very close
20:57up and there is a wealth of experimental
21:00animal data showing that if you limit
21:02Vision to just close range that the
21:06eyeball lengthens and therefore the
21:09visual image Falls in front of and not
21:11directly onto the neural retina the
21:14essentially the light sensing portion of
21:16the of the eye and those animals become
21:20myopic or nearsighted
21:23what can we say about the environmental
21:25conditions in which kids are seeing
21:29from the time they're born through let's
21:32say adolescents and their teen years in
21:35how their visual system wires up and are
21:38there any recommendations that are
21:41coming from the scientific literature
21:42clinical studies clinical trials excuse
21:45me or otherwise that indicate what a
21:48healthy visual environment consists of
21:51yeah yeah that's a great question and
21:54actually it's really relevant these days
21:57because uh you know myopia is so common
22:05an Asian populations you know it's
22:08called an epidemic in China in
22:11California we have a lot of Asian
22:13Heritage or Asian Americans and so we
22:16see a lot like at Stanford we see a lot
22:20um you know myopia in kids on adults and
22:23really starting to get thoughtful on the
22:25science of myopia control how do we how
22:28do we provide the right environments now
22:30what's interesting is that for decades
22:32the Assumption some of the data really
22:37led us to the path of thinking like gosh
22:39the more you spend near activities and
22:42these are Mouse model experiments like
22:44you described but also well-designed
22:46human cohort studies you know figuring
22:48out like asking you know kids and
22:51families like how long is your kid
22:52reading or in front of the computer how
22:54myopic are they how nearsighted are they
22:56versus how much time is your kid in
22:59front of the computer doing near work
23:01how myopic or nearsighted are they and
23:04these well-designed cohort studies did
23:06Point tour words this concept that if
23:09you do too much near work as a kid that
23:12you're more likely to develop
23:14nearsightedness as you get through those
23:16those sort of you know uh pre-teen and
23:19even into the teen years which is when
23:21most of that myopia progression or
23:23eyeball elongation is actually happening
23:26to cause nearsightedness
23:28it's only been in the last few years
23:30that some really exciting Studies have
23:32actually pointed in a slightly different
23:36and that's that maybe it's not all not
23:39to say it's not about near activity but
23:41maybe it's not all about near activity
23:43maybe it's actually a little more about
23:45the kind of light we're getting into our
23:47eyes and I think you've talked about
23:49this before and it's really important
23:51when they've now studied and asked the
23:53kids instead of just how much near and
23:55how much far are you doing how much time
23:57are you spending indoors in indoor
23:59lighting which doesn't have full
24:00spectrum light in a typical indoor
24:02environment versus how much time are you
24:05playing in the yard you could be reading
24:07outside but what are you just what kind
24:09of time are you spending outside and and
24:13of course when you're outside in
24:14sunlight even it's in direct sunlight
24:16you're getting a different spectrum of
24:18kind of Full Spectrum Lighting from the
24:20sun and it looks like it's pretty clear
24:23now actually that it has maybe more to
24:26do with outdoor lighting time than just
24:30near work and so I think that you know
24:34we we've we've actually already seen the
24:36first couple randomized controlled
24:39trials where they're having kids
24:41intentionally spending time Outdoors
24:44versus sort of Standard Life which you
24:46know is going to be often much more
24:48indoor time and uh and seeing some
24:51effects you follow those kids over a
24:53couple of years and the kids who spend
24:56time Outdoors are are progressing in
24:59their nearsightedness less like they're
25:01they're nearsighted prescription is not
25:04getting as strong as the kid kids who
25:06are spending more time indoors and
25:08there's some pretty good biology that's
25:09getting worked out going back to animal
25:11models more about about how that might
25:13be working in the retina in this inside
25:16the eye but it's pretty compelling uh
25:19concept and and so you know as a parent
25:21uh you you may want to be you may want
25:24to be telling your kid like okay yeah I
25:26want you to read that book or you know
25:28if your kids plan on the phone or
25:30something like that or the iPad or
25:32something like that they're allowed that
25:33time okay you can have that time but I
25:36want you to spend some of the time that
25:37you're doing that Outdoors are there any
25:39thresholds for the amount of time that
25:41one would suggest their child be
25:43outdoors to get that full spectrum light
25:46it's a great question you know we talk
25:48about cohort studies where we just ask
25:51people what are they doing and there
25:53seems to be you know a little bit of
25:54what we would call a dose dependent
25:56response maybe the more time Outdoors
25:58might be better we don't know if there's
26:00an upper limit like gosh if you go over
26:01two or three hours there's no additional
26:03benefit talk about that cohort studies
26:06the real gold standard for answering
26:09these kinds of questions are randomized
26:12controlled trials and specifically
26:14placebo-controlled or or a control group
26:17that's not getting the intervention
26:18that's our highest level of evidence for
26:21clinical evidence for for any of this
26:23kind of science when we're talking about
26:25humans or pre-clinical models in the
26:27laboratory and the study that hasn't
26:30been done yet to really answer that
26:32question is to randomize kids to telling
26:36this group of kids you just do your
26:38normal life tell this group of kids we
26:40want you outside an hour this group of
26:42kids we want you outside two hours a day
26:44this group occurred three hours a day
26:46and see between the groups is there a
26:49big difference like we have pretty good
26:51evidence now from the studies that have
26:52been done that the difference between
26:56and one or two hours is clearly There is
26:59five minutes enough is five hours better
27:02I don't think we know the answers to
27:04those questions yet like what's the
27:05right dose but there's probably at least
27:08some dose dependence to that and it I
27:11can imagine it's a little bit hard to
27:13tease apart the near far viewing from
27:15the indoor outdoor because yes of course
27:17a child could be outside on an iPad up
27:21but it's hard to imagine that at some
27:23point they aren't seeing off into the
27:24distance far viewing as it's called and
27:28the reverse is also true if you're
27:29indoors unless you live in a very very
27:31large home or you're staring off a
27:33balcony far viewing is much harder to
27:36achieve yeah so it's and perhaps it
27:39isn't important to isolate these
27:40variables although I can see the
27:41challenge in developing a really good
27:43clinical trial randomized clinical trial
27:45for this meanwhile I I you know I'm con
27:47I'll go into the grave shouting you know
27:50or saying rather and suggesting that
27:52people get some morning sunlight in
27:54their eyes to set their circadian rhythm
27:56um but far viewing a few at least a few
27:59minutes and ideally hours per day or a
28:02mixture of near and far viewing by being
28:04outdoors just seems like a good thing to
28:06do regardless of age so are there any
28:08data in older people not necessarily
28:11elderly but older people so um people in
28:13there from say 25 years of age into
28:16their 60s or 70s that getting outdoors
28:18and getting this full spectrum light is
28:21healthy for the eye in ways that are
28:23separate from the known healthy effects
28:25of doing that on circadian rhythm
28:26setting yeah yeah the Circadian Parts
28:32and most patients and most in most
28:34people the new the development of
28:36nearsightedness happens a lot until age
28:3810 little more through age 20. a little
28:42more than that into the in you know in
28:44through the 20s up to 30. tiny bit in
28:47the 30s up to 40. but usually by those
28:50later ages your prescription might be
28:52changing a quarter of a diopter that's
28:55the measurement that we use when we you
28:57know give you your glasses prescription
28:59a quarter of a diopter half a diopter it
29:02could get a half after more nearsighted
29:04or less nearsighted you know once you're
29:06aging into your 40s 50s and Beyond so
29:09most of the action on nearsightedness
29:12development is actually really happening
29:14in the younger ages so again the the
29:17premise of intervening in an older
29:19person and I'll just include you and me
29:21and older people for the sake of this
29:23definition as much as I'm reticent to do
29:27um I think the the premise of Inc of of
29:30sort of light modulation from
29:32nearsightedness in older people is
29:35probably probably not so strong I think
29:37there are a lot of other benefits you've
29:39talked a lot about circadian rhythm
29:41there are so many health benefits to
29:43exercise and you know if you're getting
29:45Outdoors there's a good chance you're
29:47going to be walking or bicycling you
29:49know so so exercise value for the health
29:52of our eyes and the rest of our body is
29:55um but I don't know that there's really
29:57a strong premise that you're going to
29:59change your glasses prescription you
30:01know in our 40s or 50s or Beyond I'd
30:04like to take a quick break and
30:06acknowledge one of our sponsors athletic
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30:26twice a day is that it gets to be the
30:28probiotics that I need for gut health
30:30our gut is very important it's populated
30:32by gut microbiota that communicate with
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30:57try athletic greens you can go to
30:58athleticgreens.com huberman and they'll
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31:14to get the five free travel packs and
31:16the year supply of vitamin D3 K2 it's
31:19probably worth touching on some of the
31:20do's and some of the don'ts for Eye
31:22Health generally and then I promise I'm
31:25going to get us back to adult eye exams
31:26because I have a lot of questions about
31:30I can imagine that it's probably not a
31:32great idea to be exposed to extremely
31:34bright light and this is why people who
31:36weld wear eye Shields but of course most
31:40people are not welding
31:43what other sorts of environmental
31:45conditions are detrimental to our vision
31:47health across the lifespan including
31:50brightness of light we talked a little
31:52bit about near far obviously we want to
31:55keep toxins and acids and solvents and
31:57things out of the eye but what do you
32:00I'm not because hopefully not commonly
32:02but what are some of the things that you
32:03feel might not be discussed enough in
32:05terms of Eye Health yeah you know I
32:08think at all ages eye safety is
32:12something that we don't talk about
32:15um you know our eyes are delicate the
32:19front surface of the eye the cornea the
32:21Clear Window that lets the light go into
32:23your eye that's a delicate very
32:25sensitive structure it's thin maybe a
32:28millimeter at the thickest a half
32:30millimeter in the center of our eye
32:32uh the retina is it it's neural tissue
32:36this is like really an outgrowth of the
32:37brain this is very sensitive it's
32:39subject to degenerative disease and
32:41injury our eyes even if they just get
32:44hit can get very inflamed our eyes can
32:47be more inflammatory than a bruise on
32:49our skin on our shoulder might be so eye
32:52safety is a big one and people who are
32:54working in certain industries
32:58um you know anyone who's doing any metal
32:59grinding people who are even just
33:02gardening you know and if you're if
33:03you're doing some significant gardening
33:05and cutting and you could you know Fleck
33:07a little bit of dirt you know there's a
33:09lot of there's a lot of for example
33:11fungus that lives in the ground natural
33:13stuff it's all very normal in the in the
33:15Earth but you know our eyes aren't
33:17really made to absorb that fungus and
33:21and have have a piece of dirt kind of
33:23stick in our eye like that and so people
33:26are at risk I think for you know for not
33:28and we see too much kind of
33:30really unnecessary eye injury eye trauma
33:34that if people wore either their glasses
33:37because they happen to wear prescription
33:38glasses or goggles or for more advanced
33:42work you know safety goggles of course
33:45um if you're sanding doing wood shop
33:48projects anything like that sawing
33:50including you know again in the garden
33:54um you know I think I think eye safety
33:57you know eye trauma is a big one and you
34:00know we probably see one or two
34:03um what we call open Globes a week come
34:06into the Opera into the emergency room
34:11um you know those are tough because you
34:13know again the eyes delicate and it can
34:14do a lot of healing but but not infinite
34:17right and so we really you know that's
34:19that's one that I think is really
34:22an untapped opportunity is just a little
34:24more education around
34:27um around eye protection protecting
34:29against eye trauma what about eye
34:31cleanliness there's some pretty dramatic
34:33videos also I've put some of these on my
34:36Instagram handle of these are MRIs of
34:39people rubbing their eyeballs and people
34:41really getting a sense of first of all
34:43a restatement of what you said getting a
34:45real sense of just how much the eyes are
34:47an outgrowth of the brain because of the
34:49op when you see with the optic nerves
34:51and all their beauty and the eyeballs
34:54moving around as someone rubs their eyes
34:55I have to imagine that rubbing your
34:56eyeballs a little bit isn't bad but I
34:58actually called you I don't know if you
34:59remember when I was a junior Professor I
35:01woke up from a nap one day and I
35:03couldn't see out of one eye I was
35:04freaking out so of course I called you
35:06and I had pressure blinded Myself by
35:09falling asleep on my hand or something
35:11like that and you assured me that my
35:12vision would come back and indeed it did
35:14so you play dual role of ophthalmologist
35:16and psychiatrist thank you and indeed I
35:19can see out both eyes
35:25rubbing our eyes getting gunk in our
35:28eyes you know I think unless somebody
35:29has lost their Vision temporarily
35:32it's hard to imagine this is like a big
35:34deal but when it happens it is truly
35:36frightening we're so dependent on Vision
35:39so um you know what are your
35:41recommendations about rubbing or not
35:42rubbing eyeballs about
35:44um hand washing and cleanliness and also
35:46how do you wash an eye properly yeah do
35:49you use soap and flush it with water or
35:50do you just flush it with water or
35:52should you not even do that should use
35:53saline I didn't realize these might
35:54sound like low level questions but these
35:56are the things that people deal with on
35:57an all too frequent basis yeah you know
36:00for most people most of the time
36:01actually the eyes are a very good clean
36:04environment and actually are tears are
36:08are contain enzymes that help break down
36:11bacteria and bacterial toxins and so for
36:14most people regular eye washing doesn't
36:17have to be any part of their standard
36:19routine in terms of the surface of the
36:21eye the part of your eye the conjunctiva
36:23uh over the whites of the eyes
36:25underneath the eyelids anything
36:26underneath the eyelids it's pretty
36:28self-cleaning and actually our tear
36:30production and blinking is very good at
36:33keeping our eyes clean the eyelids
36:36eyelashes can be another story and
36:39especially as we age uh we can you know
36:42like our skin is breaking down a little
36:44differently than when we were younger
36:45you can develop what we sort of
36:48nicknamed scurf which is like kind of
36:50little dead skin bits that accumulate
36:52around the eyelashes a lot of people
36:54develop what we call blepharitis which
36:56is just just means inflammation of the
36:58eyelashes yeah and for that doing some
37:01eye scrubs is a good idea they actually
37:04sell little pads that you can buy kind
37:06of little that you rip open and you can
37:08use to kind of lightly clean the
37:10eyelashes but you can also just use like
37:13a No More Tears baby shampoo just pump a
37:16little bit into the palm of your hand
37:18once or twice a day let a little uh
37:21dilute it with a little water and under
37:23the sink and either with your finger or
37:25an edge of a washcloth just very lightly
37:27rub the eyelashes what I like to do with
37:29the eyes closed with the eyes closed and
37:31don't scrunch them closed too tight
37:34because you're actually burying the
37:35eyelashes when you do the roots of the
37:38eyelashes when you really scrunch so
37:40just gently close your eyes just you
37:42know real gentle closure and then just
37:44lightly scrub it shouldn't be abrasive
37:46you're not trying to exfoliate the
37:48eyelids or eyelashes in any way just
37:51lightly rub with that kind of dilute No
37:53More Tears baby shampoo and that can
37:55really help people with their eye
37:58Comfort if you feel like you've got
38:00something in your eye your ideal eye
38:03wash is actually going to be a sterile
38:05Salient solution a saltwater solution
38:07that you know they sell little bottles
38:09over the counter eye wash Solutions like
38:12that a lot of people wear contacts will
38:14have that kind of eye wash solution just
38:16a sterile saline eye wash just pure salt
38:20water doesn't have to have any other
38:21chemicals or preservatives in it you can
38:24of course use not actual uh seawater or
38:27salt water not salt water thank you yeah
38:29not salt water out of your salt pool not
38:31salt water out of the ocean but like a
38:34saline salt water that's available in a
38:36sterile now you can also just use
38:38artificial teardrops and some of those
38:40common non-preservatives some of those
38:42come preserved versions those are all
38:44also completely safe in the to use in
38:46the eye and there you can you know you
38:48can sort of Spritz into your eye you
38:50know hold the lid open and give it a
38:52little Spritz if you feel like you've
38:53got something in your eye a piece of
38:55dirt or A Lash that's not coming out
38:57just to rinse it but but having like a
38:59regular routine you know you're not
39:02going to hurt anything with the
39:04occasional eye rubbing we all do these
39:06things just kind of as a you know even a
39:08nervous habit or just absent-mindedly
39:10you know you might you know scratch your
39:12arm or rub your eyes or things like that
39:14that's fine you're not going to hurt
39:16anything there are conditions where
39:18people sort of develop kind of a almost
39:21like a psychological habit there are
39:23certain conditions where people actually
39:25do too much eye rubbing it can be
39:27dangerous if you're in that group but
39:28for the regular run-of-the-mill every
39:31day occasional I rubbing fine if you
39:34certainly if you get a lash in there and
39:35you're trying to rub it and blink it and
39:37tear it out and again in that situation
39:40you can use some artificial tears
39:42wedding drops saline drops those would
39:45be the way to do it what an incredible
39:47tissue the way you describe it you know
39:50the self-cleaning and yet so delicate
39:53a piece of the brain literally lining
39:55the back of each of our eyes like like a
39:58pie crust I mean it's a really
40:01um biological system of course I don't
40:03have to tell you that it's just it it
40:05never ceases to to amaze me
40:08let's talk about eye exams in adults
40:12people are aware presumably that they're
40:15optometrists and ophthalmologists I
40:17think it's important that we Define
40:18their different and also overlapping
40:23for those that you know are past High
40:25School age probably not getting eye
40:26exams unless they're sensing a problem
40:29perhaps not even with blurry vision or
40:32difficulty seeing at a distance but
40:34sometimes just what feels like fatigue
40:37of the eyes or a hard time maintaining
40:39alignment of the eyes
40:41um so how often do you recommend people
40:42get eye exams what is a true regular eye
40:45exam and is it important that people go
40:47to an ophthalmologist or will an
40:49optometrist suffice typically
40:51optometrists are a little bit easier for
40:53most people to access because there's
40:54usually one someplace near an eyeglass
40:56store so what are their roles how often
40:59should we get our eyes checked yeah
41:02um optometrists and ophthalmologists do
41:04have very overlapping roles in being Eye
41:08Care Providers there are something over
41:1040 or 50 000 optometrists in the United
41:13States or somewhere around 20 000
41:16ophthalmologists in the United States
41:18optometrists get an optometry degree
41:21they often have OD after their name
41:24ophthalmologists usually went you know
41:26went to medical school so they either
41:28have an MD after their name or they kind
41:30of a do version of a medical degree and
41:34uh and then optometrists will have done
41:36additional clinical training in that
41:38area in their area of Eye Care provision
41:41ophthalmologist MD doctor
41:43ophthalmologist Eye Care providers in
41:46addition to that training will have done
41:48surgical training in Ophthalmology
41:52um now there's a lot of overlap and
41:56um in both scenarios uh you can be
41:59getting your sort of General exam taken
42:01care of maybe a screening exam I think
42:04that there's been a traditional
42:06differentiation between optometrists and
42:09ophthalmologists with optometrists
42:11providing a little more of the primary
42:14care eye screening maybe managing early
42:18disease common diseases as well with
42:22more advanced disease often sort of
42:24upgrading to perhaps specialist
42:27ophthalmologists in those areas but that
42:31distinction has been declining over time
42:34it's still true that in I think most if
42:36not all states only the MD
42:38ophthalmologists surgeons can do eye
42:41surgeries but both both groups of eye
42:45care providers can diagnose both can
42:48prescribe appropriate eye drop
42:51treatments including prescription eye
42:53drop treatments for for many of our
42:55diseases eye diseases
42:58and um and in some states
43:01optometrists have successfully lobbied
43:04for uh sort of expanded rights of
43:06providing Air Care Eye Care and again
43:09um access to care for you know the
43:12regular person wherever they may live is
43:15is the most important element and so
43:18being able to access eye care whether
43:20it's with an optometrist in your
43:22community or an ophthalmologist that may
43:24be in your community or maybe at a
43:26distance I think that's the the really
43:28important thing is to access care now
43:30kind of like we were talking about with
43:32kids uh if you're in your teens 20s
43:35maybe even 30s and not having any
43:38problem you've got no complaints you can
43:41see a distance you can see it near
43:44um you know so you can read without
43:45classes you can drive without classes
43:49um you're not having any eye pains you
43:51know pains around the eyes you know
43:54redness of the eyes you may never
43:57present to an eye care provider through
44:00the first four Decades of life
44:02and almost all the time it's going to be
44:06okay right if you're not symptomatic the
44:09chance you've got some terrible lurking
44:11disease in there is low
44:15but we do wish that we had a little more
44:18screening going on because there are
44:20some diseases glaucoma for example my
44:22specialty the two main risk factors for
44:25glaucoma are increasing age and that
44:28usually presents you know in most cases
44:30actually after age 40 but also
44:33increasing eye pressure and if your eye
44:35pressure is too high you can't feel that
44:37that won't feel funny to you if it sort
44:39of slowly is crept up over the years and
44:42so from a screening perspective it is
44:44good to get some kind of screening exam
44:48could be at a public health fair could
44:50be that you go into the local
44:51optometrist just say hey I've never been
44:54checked I'd like to be checked once make
44:56sure everything's good could you ask for
44:57sorry to interpret could somebody say
44:59I'd like my pressures checked as I
45:01recall the optometrist they're going to
45:02do a puff test so they're going to blast
45:03some air get a sense of how how rigid or
45:06or soft again using non-clinical
45:09non-technical language here the eyeball
45:13um not right now by the way I'm sure
45:14there are are several hundreds of
45:16thousands of people who are with eyes
45:18closed touching the sides of their
45:19eyeballs and I'm only half joking please
45:21don't do this folks I'm given the
45:23conversation we just had about eye
45:24cleanliness and eye rubbing but my
45:26understanding is that the old fat truly
45:28old-fashioned eye pressure exam was you
45:31would close your eyes and the
45:32ophthalmologist would gently press to
45:35see whether or not your eyes were more
45:37rigid than last time yeah is that right
45:38yeah that's called ballot mint and you
45:40can kind of you can you can kind of just
45:42take one second if you're listening and
45:44press on your eyes just very lightly and
45:46you there's a little give of course the
45:48eyelids part of that give but but it's
45:50not it's not like rock hard and if we
45:52press and it feels under the eyelid like
45:55gosh something under there is a rock
45:57hard then we know something is wrong
45:59that is way too high pressure if it's
46:01raw card but I'll tell you our ability
46:03to differentiate the fine points of eye
46:05pressure other than Rock Hard or not
46:09rock hard is pretty limited so yeah the
46:12optometrist office or the
46:14ophthalmologist office office as part of
46:16a comprehensive screening exam they'll
46:18check the eye pressure they'll look at
46:20the surface of your eyes make sure
46:21everything's looking healthy there
46:23including the eyelids and lashes and
46:25they'll look inside the eye and be able
46:26to screen for these diseases that way
46:28too in addition to checking if you're
46:30complaining of any you know blurriness
46:32at distance or at near now after age 40
46:36or so a lot of people will present to an
46:40eye care provider because we all get
46:42what's called presbyopia and presbyopia
46:46just translates to disease a vision of
46:50the agent so you know myopia is our word
46:53for nearsighted hyperopia is farsighted
46:56actually amatropia means normal sighted
46:59so I can see it distance without any
47:00glasses I'm amitropic
47:03but then we all get presbyopia and as we
47:07age the lens inside our eye that's
47:10helping focus light onto our retina gets
47:14such that our eye muscles are no longer
47:17able to relax and reshape that lens and
47:20we're not as good as we age at
47:23moving our Focus from distance Vision
47:26distance Vision by the way is basically
47:28anything three feet or further away
47:30You're basically viewing light rays
47:33coming from Infinity once you're past
47:35three feet so three feet or further
47:38being able to focus that into 14 inches
47:40or 12 inches which might be a normal
47:42comfortable reading space for you
47:45we lose that ability to flex our lens
47:48relax our lens uh refocus our lens from
47:52distance to near and most people around
47:55age 40 could be a couple years before
47:57could be five or ten years later that
47:59you notice it but sort of around that
48:01time you start needing reading glasses
48:04you need a little extra even if you can
48:06see fine at distance and don't need
48:08prescription glasses for distance you
48:10need a booster you need reading glasses
48:12for near I don't know if you're
48:13experiencing this yet and yeah I'm
48:16really intrigued by this but maybe you
48:18could clarify when you say reading
48:20glasses do you mean just a magnifier
48:22because I use a you know a 0.5 or a 0.75
48:25magnifier for reading but I try and rely
48:29as little as possible and I want to get
48:31to this about using glasses as a crutch
48:33and the problems with that I have a
48:36story about that too you know it's no
48:38coincidence I decided to work on Vision
48:42um I had a bunch of vision issues that
48:44fortunately are corrected but you know I
48:47I do experience for instance when I wake
48:49up in the morning if I look at my phone
48:51which by the way folks I try and get
48:53outside and see sunlight first before
48:54ever looking at the phone but I'll
48:57notice when I first look at my phone in
49:00the morning that I can see it very
49:02clearly through my right eye but that if
49:04I cover my right eye my left eye is
49:06extremely blurry to the point where I'm
49:07like oh I'm calling Jeff you know I'm
49:09I'm afraid but then over the course of
49:11maybe 10-15 minutes it resolves and I
49:13don't think it's because something's in
49:15my eye I don't think it's pressure of
49:17having slept on that side I don't think
49:18it's a lubrication of the eye issue
49:21um but the two eyes seem to come into
49:23Focus so to speak um at different rates
49:26early in the day and if I pop my readers
49:29on I can see right away so I will use
49:31readers late in the day often
49:34um if I want to read at night or
49:35something that's right just it feels so
49:37much more relaxing I feel like like I
49:39can finally relax whereas otherwise I
49:41realize that I'm straining in order to
49:43see does is there any um clinical
49:45clinical data and what I just described
49:47yeah you know Andy I'll tell you my
49:50story that's like that and
49:52um we were living down in San Diego when
49:55you and I were both professors at UC San
49:57and uh we had moved into a house and I
50:02found a pair of glasses a pair of
50:04reading glasses uh in a closet and you
50:07know we asked around you know did any of
50:09the grandparents uh leave some glasses
50:11behind nobody seemed to know who they
50:13were so we finally just decided like
50:15well I guess the people who moved out of
50:17the house just left a pair of glasses
50:19you know in this in the back of this
50:21and then I tried the glasses on
50:24and I looked at my phone up close and
50:27was just like oh my God wait a second I
50:30didn't realize how blurry my near Vision
50:33was and this is back I was about 40 42
50:36something like that so
50:38so I didn't even realize until I put on
50:41the readers and these were
50:43you know 1.25 magnifiers you know so
50:52I got addicted because who doesn't like
50:55good Vision right right I mean oh my God
50:57now I can make the type smaller on my
51:00phone I can you know it was wonderful
51:02and you can relax a bit I mean the
51:04musculature that's responsible for for
51:06moving the lens and focusing the eye and
51:07then all this extraocular musculature
51:09and we forgot I mean I'm definitely
51:12um around my eyes uh probably because I
51:16you know squint or something but you
51:18know just the ability to relax one's
51:20face it just feels like you know more
51:22more energy I feel like can be devoted
51:24to what we're actually looking at yeah
51:25we're not making light of this yeah well
51:27pretty soon I just kept that one pair of
51:30glasses with me all the time and I would
51:32just keep them in a pocket and whip them
51:34out whenever I was you know working at
51:35near using my phone at a little greater
51:38distance like a typical computer
51:39distance I could still see the computer
51:41fine so it really started for like kind
51:42of that close-up phone it was it was I
51:45could get into here but not all the way
51:48and um yeah and then pretty soon I was
51:51just totally addicted and so you know
51:54then I had to go buy 10 pairs and leave
51:57them one by the bedside table you know
52:00one in the car one in the computer bag
52:02one on everything I work at yeah because
52:05I'd leave them anywhere and forget them
52:07yeah exactly you know yeah
52:14whether using the readers
52:18accelerates the progression of
52:22dependence on the readers is still uh
52:27not you know that's still up for debate
52:29you know some studies say maybe yeah
52:31some studies say maybe no but certainly
52:34psychologically we get addicted to good
52:37easy vision and if you don't have to
52:39squint and if you're not straining your
52:42muscles and all of a sudden the text on
52:44your phone looks crisper again uh boy
52:47that's addictive you're gonna like good
52:49vision and so it feels like you're
52:51getting dependent and how much of that
52:53is changing the eye muscles and how much
52:55of that is just the psychology of
52:57wanting to have good Vision I think
52:59probably the jury's a little bit out on
53:00that point but point being you're either
53:03either way your dependence will grow and
53:06as you continue to age 40s 50s up until
53:12the ability to shape that lens gets
53:15weaker and weaker and weaker and so you
53:18need to move from the 0.5 to the 1.0 to
53:21the 1.5s and to the coke bottle to the
53:25code well thankfully not you eventually
53:27max out at about plus 2.5 or plus three
53:31because that's the amount of extra
53:34refractive power that you need in
53:36magnifiers to take the equivalent of
53:39your Infinity viewing and bring it up to
53:4214 inches to read it near basically you
53:45need a plus three and then you don't
53:49lens eye muscle action whatsoever so you
53:54kind of max out around 2.5S or threes
53:57so because most people will hit this
54:01somewhere in their 40s this sort of like
54:03gosh I'm having trouble on the phone
54:06I think most people actually use that
54:08that's like kind of the first time for a
54:10lot of people they're like well I guess
54:12I should go to the eye office right see
54:14the optometrist or maybe ophthalmologist
54:15and when they go in they should be
54:18getting the standard in either of those
54:20offices will be to give you a full
54:23screening exam including maybe it's the
54:26puff test or a blue light test or a
54:28little pen that can check your eye
54:29pressure and having a look inside and
54:32seeing if you're retina optic nerve look
54:34healthy it's kind of screening for all
54:36the main diseases and so and they'll
54:39tell you at that point hey you look
54:41great if you feel like your glasses
54:43aren't doing it for you in a year or
54:44three years come back or they might say
54:47hey I've detected something I'm worried
54:49about you and they'll set up a routine
54:51for your ongoing Eye Care
54:54assuming that somebody doesn't have
54:57um you know some form of amblyopia or
55:00the need for some a really robust
55:04and they are already using readers let's
55:10or so you know plus one plus or minus
55:14would you recommend based on my
55:16experience and based on your experience
55:17that people strive to avoid using them
55:20for as long as they can because in some
55:23sense if that's the recommendation then
55:26the recommendation is that people kind
55:27of deal with the fact that they're
55:28seeing a little less well or a lot less
55:30well than they possibly could so I'm
55:31assuming that people can still drive
55:33well people can still read but it
55:35involves a little bit more effort in
55:36other words are we weakening Our Eyes by
55:38using these these readers I I realize
55:40you said that the data are a little bit
55:41mixed but as long as one can perform
55:44their required daily activities would we
55:48delaying the use of readers
55:51there's two important answers to that
55:54question one is regarding the lens and
55:58the eye muscles that control the lens
56:00and it's entirely plausible that's what
56:03I was saying kind of the data is mixed
56:04on but it's plausible that if we would
56:06just exercise like work a little harder
56:09kind of not use as strong a reader as we
56:12want or not use that reader as often as
56:15we might really enjoy uh are we
56:18exercising those muscles and kind of
56:20exercising the ability to to stretch
56:23versus relax the lens and kind of slow
56:27the progression from the 1.0 reader to
56:31the 1.25 reader to the 1.5 reader Etc
56:34right and so that that's why I'm saying
56:36the data is mixed but there's a good
56:38premise that maybe if you're exercising
56:40but let me give you the on on the other
56:42hand it's probably ideal
56:46to give your retina and your brain the
56:50sharpest visual signals you can
56:53so why hamstring your retina and your
56:58brain and your vision and your enjoyment
57:01and ability to read or do near work by
57:05constantly undercutting the the reading
57:08glasses or leaving them out or you're
57:12not helping the whole back part of yours
57:15maybe you're maybe you're helping the
57:17lens but you're definitely not helping
57:19your retina and brain by feeding it
57:21blurry information all of that time so I
57:25actually think just give in use the
57:29readers have your enjoy your Best Vision
57:32all the time and if that means wearing
57:35glasses and by the way if that means
57:37that you're going to have minus two
57:39glasses for vision and you'll eventually
57:41need minus 250s for distance Vision or
57:45if you're going to need readers 1.5
57:47readers now and in a few years 2.0
57:50readers okay so you'll get the next
57:53reader it's it's it's actually not a big
57:55deal you can you can you know you're not
57:57you're not hurting you're probably
57:59helping and in the meantime it's an
58:02enormous enjoyment to actually have good
58:04Vision all the time right so so I
58:07actually counsel people
58:09just wear the glasses that work best for
58:11you you know you're only minimally
58:13changing how your prescription is going
58:16to change over time very minimally so
58:18just enjoy your Best Vision even if it's
58:22using readers for clothes or
58:23prescription glasses for far
58:26I appreciate that recommendation I do
58:28enjoy you using the readers at night it
58:30really helps for all the reasons I
58:35I've noticed that driving at night
58:37presents an enormous strain on my visual
58:39system and I've noticed this for a
58:40number of years are there any I know
58:43there's something called stationary
58:44night blindness I don't think I'm
58:45stationary night blind
58:47um I think the mutation for stationary
58:49night blindness was identified in the
58:51Colusa horse or something like that
58:53these were horses that you could walk up
58:54to very easily and they wouldn't even
58:56see you until you're right there
58:57someone's going to correct me on this
58:58it's the internet but I think that the
59:00mutation was identified
59:02um Etc but I don't think I'm stationary
59:04night blind but I do find that driving
59:06at night I get very fatigued and then
59:10I'll sometimes even wear my plus one
59:11readers when I drive at night which
59:15removes the fatigue even though I'm
59:17looking more or less at a distance are
59:19there some conditions that make it hard
59:20for people to see at night for which
59:22they would want corrective lenses
59:25um and what what sorts of biology
59:27underlies that assuming that somebody is
59:30not stationary night blind or a Colusa I
59:33think is the name of the breed horse
59:35yeah that's a great question you know we
59:38for the for the optical defects in our
59:41eyes most or many of which can be
59:44corrected with just having the right
59:45prescription lenses we can get away with
59:49it without using those Corrections in
59:53and so during the daytime
59:56um you know you could be slightly blurry
59:59you know if I have a real bright light
01:00:02uh and a good high contrast book you
01:00:05know with black letters on the white
01:00:06page I can get away with reading that
01:00:08without my readers unlike if if I'm in
01:00:12dim light then I feel and that might be
01:00:13kind of what you're describing if you're
01:00:15reading at night you actually prefer to
01:00:16use the readers a little more even at
01:00:18night because we can make up for a lot
01:00:21of that blur if we just have bright
01:00:24enough signal and contrast coming into
01:00:26our eyes makes sense yeah so when you're
01:00:29driving at night and noticing this this
01:00:31might be revealing a little bit of a
01:00:33need for glasses now I'm not suggesting
01:00:36this is the answer but far more common
01:00:39than having congenital stationary night
01:00:42blindness would be being what's called a
01:00:45latent hyper rope okay now we talked
01:00:49about already how the lens inside our
01:00:51eye goes from focusing it distance to
01:00:54then we squeeze the muscles the lens
01:00:56actually rounds up and allows us to
01:00:59some people's Optical system of their
01:01:02eye is actually wired or designed or
01:01:05sort of set up in length not for regular
01:01:09distance which would be anywhere from
01:01:10about three feet to Infinity
01:01:13but it's actually designed it's actually
01:01:15tuned for being beyond Infinity which
01:01:18doesn't make any actual sense when you
01:01:20talk about it but just the Optics of the
01:01:22eye at their best Focus are actually
01:01:24focusing the light behind the retina and
01:01:27and if you're doing that when you're
01:01:30younger you're actually using some of
01:01:32your focusing power to to use those
01:01:35muscles strain those muscles relax that
01:01:38lens round up that lens and have your
01:01:41vision Focus From Beyond Infinity to
01:01:45normal distance like distance vision and
01:01:49so if you're a latent hyperope you are
01:01:51constantly using those muscles and again
01:01:54if you're tired it's the end of the day
01:01:56your muscles are feeling a little
01:01:57fatigued uh your latent hyperopia or by
01:02:02the way if you've had a drink or two
01:02:04alcohol can do this too your latent
01:02:07hyperopia can kind of kick in especially
01:02:10as we're age and we're not as good at
01:02:12refocusing that lens anyway and now all
01:02:15of a sudden your vision is kind of
01:02:18reverting to its natural state which is
01:02:21slightly out of focus at distance
01:02:23because it's actually focused beyond
01:02:25Infinity if you will and so all of a
01:02:28sudden you put on that plus one just for
01:02:30a little extra booster kick and you're
01:02:31like oh yeah yeah distance vision is
01:02:33clean and easy now so
01:02:35I'll have to bring you into the clinic
01:02:37to really be sure but you could be
01:02:39exhibiting a little bit of that kind of
01:02:41latent hyperopia I definitely want the
01:02:44eye exam and I want it from you and I've
01:02:45been called a lot of things in life um
01:02:47and we can now let add perhaps latent
01:02:55I'd like to take a quick break and thank
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01:03:54off another easier and again this
01:03:57discussion is not designed to be an eye
01:03:59exam for me but I have yet another
01:04:01experience that I think illustrates the
01:04:04key importance of both critical period
01:04:06plasticity and the questions about
01:04:09whether or not to rely on corrective
01:04:11lenses and that is from the time I was
01:04:13pretty young I could make my sister
01:04:14laugh by deviating one eye inward so not
01:04:17crossing my eyes but moving one eye
01:04:19Inward and then what happened was when I
01:04:21was in college and studying a lot a lot
01:04:24and getting very fatigued I noticed that
01:04:26this I started just kind of drifting a
01:04:28little bit so I went to the campus
01:04:31Health Center and they gave me a
01:04:33prescription for a prism lens which of
01:04:36course redirects the image but then I
01:04:38noticed that this eyeball moving Inward
01:04:40and I guess for those of you watching on
01:04:42uh on YouTube and not just listening um
01:04:46um by just moving one eye in all right
01:04:48as I can move this side yeah it's a
01:04:50fairly pronounced it started to really
01:04:51drift in at a relaxation State and I
01:04:54started seeing double again so I thought
01:04:55whoa these prism this one prism lens is
01:04:59a crutch of the sort that I really don't
01:05:00want crushed the glasses it broke them
01:05:03and it never went back to them
01:05:05um I have voluntary control over it but
01:05:07that's one example where the corrective
01:05:10lens can actually create a pretty
01:05:12significant shift in eye position if one
01:05:14relies on it so this gets back to this
01:05:18um when should people Force themselves
01:05:20to work with their natural vision maybe
01:05:23do some more far viewing
01:05:25um as opposed and certainly get outside
01:05:26and get sunlight into the sunlight full
01:05:28spectrum light as opposed to relying on
01:05:30active lenses yeah and and you've raised
01:05:33a very important distinction here and
01:05:36that's the distinction between the
01:05:38muscles that are inside our eye that we
01:05:41use to relax and refocus the lens and
01:05:44the muscles that are on the outside of
01:05:45the eyeball of course inside our orbit
01:05:48but on the outside of the eyeball that
01:05:49turn the eyes and if everything's
01:05:52working right keeps our eyes really
01:05:54yoked straight and we talked about
01:05:56earlier uh this possibility that you may
01:05:58have been having a little bit of
01:06:00intermittent esotropia or intermittent
01:06:03turning in of the eyes that then
01:06:05culminated on that day of a day at the
01:06:07pool when you really noticed it
01:06:09and your ongoing ability to actually
01:06:12turn one eye in could be related to that
01:06:15I remember as a kid standing in front of
01:06:17the mirror and I I couldn't get my eyes
01:06:19to cross even though friends could do it
01:06:21and you know so you know I I was in the
01:06:23losing group on that on that end you
01:06:25became an ophthalmologist and then I
01:06:27became an ophthalmologist and I must say
01:06:28it is very reassuring that you have
01:06:30excellent Vision you know I always worry
01:06:32when I go to a new dentist and then I
01:06:33look up at them in one moment and if
01:06:35they're not wearing a mask that their
01:06:36teeth are not you know pristine I think
01:06:38well what am I doing here so at you know
01:06:40an ophthalmologist with excellent Vision
01:06:42brings me uh great comfort the toddler's
01:06:45children should have shoes right exactly
01:06:48um but yeah so so when to correct when
01:06:51not to correct with lenses and I realize
01:06:53here we haven't talked at all about
01:06:54contacts we've been talking about
01:06:55eyeglasses yeah let's come to contacts
01:06:58in a sec if you want but yeah let me
01:07:00return to your question the difference
01:07:02between providing corrective lenses that
01:07:05allow you to focus for near or distance
01:07:08uh in your glasses so that you can go
01:07:12easy on the inside the eye eye muscle
01:07:15having to work so hard a lot of people
01:07:16get eye strain and sort of uh headaches
01:07:19even from that from not having adequate
01:07:21correction that they're wearing that's
01:07:24different actually especially when we're
01:07:26children or again into that maybe even
01:07:28into the teens and even young adult
01:07:31from the eye muscles on the outside of
01:07:33the eyes which are supposed to be yoking
01:07:35our eyes straight and so that you have
01:07:37them both looking at the same point in
01:07:38space and and there it's actually quite
01:07:42a common treatment to try to under
01:07:44correct and ask people to exercise and
01:07:48not just give a prism that says hey if
01:07:51your eyes in sometime we'll use a prism
01:07:53so the light sort of looks right to you
01:07:55but rather under correct that and sort
01:07:58of really force you to exercise trying
01:08:01to yoke your two eyes straight together
01:08:03and so that's that's in contrast and
01:08:06they're actually I think many
01:08:08optometrists who often specialize in in
01:08:11what are the right glasses to give in a
01:08:13situation like that wherever possible
01:08:16especially during
01:08:19uh development as our bodies are
01:08:21developing as we're sort of growing in
01:08:23our younger years uh take the approach
01:08:26of intentionally trying to under correct
01:08:28not use a prism or not use a full prism
01:08:31correction uh and um to really help uh
01:08:36sometimes it's also like an
01:08:38accommodative reflex that your eyes are
01:08:40just you're spending so much time
01:08:41reading it near when you read it near
01:08:43your eyes actually naturally turn in a
01:08:45little bit to focus uh at that nearer so
01:08:48that they can be looking at the same
01:08:50word on the page and that can also if
01:08:53you've got kind of too much muscle drive
01:08:55you can overshoot that and so sometimes
01:08:57just using not a prism but like a little
01:09:00bit of a plus lens in kids just so they
01:09:02don't have to work quite so hard to turn
01:09:04their eyes in and sort of over exercise
01:09:07those muscles these are all great
01:09:09examples we're going to an eye care
01:09:11provider often for these kinds of issues
01:09:13an optometrist is the right first place
01:09:16you'd like to say that every optometrist
01:09:18and every ophthalmologist is always
01:09:20going to give the exact right thing for
01:09:22for each kid or young adult or older
01:09:24adult to do and and we wish all medical
01:09:27care providers were were always right on
01:09:29Target and a lot of times it's a perfect
01:09:32science but a lot of times it's an
01:09:33imperfect science and so it could be
01:09:36that at least with you know we're now 20
01:09:3825 30 years later but like it could be
01:09:41that today that 20 year old version of
01:09:44yourself would have been given a
01:09:46different uh approach to having one eye
01:09:49intermittently occasionally turning in
01:09:51like that is there any real value to
01:09:55um near far exercises you know so-called
01:09:57pencil push-ups or a smooth Pursuit
01:10:00tracking I've talked a little bit about
01:10:01it before on the podcast but that was
01:10:03you know some time ago so what are your
01:10:05thoughts on on that is there any value
01:10:07whatsoever I mean they require a little
01:10:09bit of work just like going to the gym
01:10:11but you know you know 25 reps a day of
01:10:15um especially as one is transitioning
01:10:16from age 30 to age 50
01:10:19um is it worthwhile yeah is it harmful
01:10:21in any way definitely not harmful and
01:10:24again uh you know would it slow down or
01:10:28sort of uh slow down your progression to
01:10:31presbyopia or needing those reading
01:10:33glasses uh could be some people also
01:10:37um sort of uh you know a real failure to
01:10:40properly turn their eyes in and so they
01:10:42actually would benefit if you've been
01:10:44diagnosed with that inability or having
01:10:46double vision at near but not at
01:10:50um so that kind of convergence in
01:10:52insufficiency for example then then
01:10:56pencil push-ups off and get prescribed
01:10:58as a way to try to exercise those skills
01:11:00and you know uh in your eye muscles I
01:11:03should interrupt here and just tell
01:11:05people for those of you that are
01:11:06listening not watching the pencil
01:11:07push-up we can put a link to it in the
01:11:10show note caption so it's essentially
01:11:11taking a pen or pencil looking at it at
01:11:14um at arm's distance and then slowly
01:11:16moving it toward your nose and
01:11:18deliberately working hard and it is a
01:11:21bit of effort to continue to focus on it
01:11:23at a close distance at some point it
01:11:25will become blurry because I can't cross
01:11:28my eyes any further unless I become a
01:11:30cyclops and then moving it back out
01:11:32again and doing that for you know 10 to
01:11:3425 repetitions maybe once or twice a day
01:11:37a few times a week that's what those are
01:11:39pencil push-ups yeah yeah so
01:11:42um you're certainly not going to hurt
01:11:43anything there are other situations
01:11:46where those really do get prescribed and
01:11:48there's definitely some good clinical
01:11:50trial data suggesting that they can
01:11:52actually help for example recovery from
01:11:54concussion a lot of people actually
01:11:57one of the really telling ways to
01:11:59diagnose concussion and this can be
01:12:02concussion from sports or a fall or you
01:12:04know any any source of concussion your
01:12:08smooth Pursuit which is the ability
01:12:10let's say I've got a DOT moving around
01:12:11in a circle on a screen and I'm
01:12:14following that thought with my eyes my
01:12:16eyes should be able to very smoothly
01:12:18follow that circle around
01:12:21watching a hockey game is that like your
01:12:24body fan right like that you know just
01:12:26following a ball you know following any
01:12:28movement with smooth Pursuits of your
01:12:31and after concussion that actually those
01:12:34systems in our brain the sort of
01:12:36reflexive ability to properly follow
01:12:38that use that visual input to tell your
01:12:41eye muscles exactly where to move
01:12:43gets disrupted and so all of a sudden
01:12:45your smooth Pursuit starts to look
01:12:47choppy it's not so smooth anymore and
01:12:48it's actually a way to diagnose and
01:12:51follow recovery from concussion and part
01:12:55of the visual rehab sort of neuro rehab
01:12:59one of the approaches being used and
01:13:01further studied still in recovery from
01:13:04concussion is actually doing those kinds
01:13:06of exercises like pencil push-ups or
01:13:09basically what you've described is
01:13:12focusing from far away to focusing near
01:13:14and doing that back and forth and using
01:13:16that to sort of like help regain uh the
01:13:20tighter control of our eye movements and
01:13:23that eye brain connection so if
01:13:25traumatic brain injury causes deficits
01:13:28in smooth Pursuit eye movements and some
01:13:29of the recovery protocols for traumatic
01:13:32brain injury are to have people do
01:13:34smooth Pursuit protocols and pencil
01:13:35push-ups are these also the sorts of
01:13:37things that anyone can just do I mean
01:13:40whenever possible we like to share tools
01:13:44for various aspects of Health on this
01:13:46podcast but of course we don't want
01:13:48people cowboying this stuff in a way
01:13:50that could be detrimental to their to
01:13:52their Vision so is it okay to get on
01:13:54YouTube and find a smooth Pursuit um
01:13:57Tool uh we can put a link to these there
01:14:00there are several of them
01:14:01um and people spend a few minutes doing
01:14:04you're definitely not going to hurt
01:14:06anything so totally fine to do it and
01:14:09some people may notice you know like
01:14:11they feel a little more visually active
01:14:14if they do these kinds of exercises
01:14:17um I think most people would do them and
01:14:19not notice something in their daily life
01:14:24made so much progress you know in
01:14:27research in thinking about how do we
01:14:30take the diseased or dysfunctioning or
01:14:34aging eye and get it back to healthy and
01:14:39but there's a whole other area of
01:14:42science that's we're really just barely
01:14:44touching we've actually we've actually
01:14:46just opened a vision performance center
01:14:50to really get at not just how do we
01:14:52rehab the sick eye back to health but
01:14:56what's the difference between
01:14:57functioning normally and functioning
01:15:01for example athletes when they get
01:15:04studied for visual Vision
01:15:06characteristics they have faster visual
01:15:09reflexes higher visual Acuity uh how
01:15:13much of that was you know genetic how
01:15:16much of that is trained we don't really
01:15:18understand could we train all of us with
01:15:20you know normal vision to get up to
01:15:24Supra normal vision these are like great
01:15:27important questions that are really
01:15:28relevant to you know every regular
01:15:31person of course you know people doing
01:15:33Esports and the gaming communities and
01:15:36athletes is part of what we're studying
01:15:38in the vision performance center but
01:15:39these are really really big
01:15:41opportunities to try to understand how
01:15:44do we move people from normal vision to
01:15:46Super normal vision and there's evidence
01:15:48that you can do it so here's a great
01:15:50example some athletes train
01:15:53using these special goggles that
01:15:57actually use electrical signals in the
01:15:59glasses part of the goggles to actually
01:16:01black out your vision one thirtieth of
01:16:05every second two thirtieths of every
01:16:07second three thirtieths of every second
01:16:10now imagine you and I are passing a
01:16:12basketball back and forth except you're
01:16:14wearing goggles and all of a sudden
01:16:16you're only getting 90 percent of the
01:16:19data of where's that basketball on its
01:16:21way to my hands now you're only getting
01:16:23eighty percent now you're only getting
01:16:2570 percent of that visual information
01:16:27and you are practicing right you are
01:16:30getting good at catching a basketball
01:16:32when you only have a fraction of the
01:16:35visual information and now I put you
01:16:37back on the basketball court without the
01:16:39goggles you might be really good at
01:16:43passing that basketball around and
01:16:45catching that basketball right and so
01:16:47the idea that we could train and
01:16:49understand the biology of training to
01:16:52get the eyes from normal to supernormal
01:16:55Performance I think it's an amazing area
01:16:57and one that we've really just started
01:16:59to dig into that's fantastic so this is
01:17:02a a new program at Stanford through the
01:17:04department of Ophthalmology is it linked
01:17:07up at all with the woosai performance
01:17:08Institute yeah actually there's been a
01:17:11lot of focus over the years I think in
01:17:13human performance and there's actually a
01:17:15new human performance uh Alliance and
01:17:18Center we've we've we've long had really
01:17:21run through the department of our
01:17:22Orthopedics a human performance
01:17:25laboratory that's really you know much
01:17:27more about joints and muscles and
01:17:30strength and conditioning and stretching
01:17:33to layer on to that now a real
01:17:36understanding of how vision is operating
01:17:38you know it's interesting let's go back
01:17:41to the example of concussion you know
01:17:43we've got I don't know about 800 Varsity
01:17:45student athletes and all the different
01:17:47sports at Stanford and you might have a
01:17:50student athlete come in and say you know
01:17:52something doesn't feel right I got a
01:17:54little hit on the head I feel like my
01:17:56vision is a little bit messed up maybe
01:17:58I've got a mild concussion you could
01:18:01imagine doing some of these tests on
01:18:04some of these performance athletes for
01:18:06example and saying well gosh you look
01:18:10but actually they used to be operating
01:18:13at a supernormal rate and this is a
01:18:15noticeable decrement for them and so
01:18:18just starting to study and understand
01:18:20what's the difference between normal and
01:18:22supernormal how do we go back and forth
01:18:25between those two how do we measure that
01:18:26difference and maybe ultimately how do
01:18:28we train into that difference I think
01:18:30it's going to be exciting and not just
01:18:31for athletes you know for for regular
01:18:33people you know you talk about driving
01:18:35at night is there a solution where we
01:18:37could train our eyes to be better at
01:18:40driving at night and I don't know maybe
01:18:41reduce the number of accidents that
01:18:43happen out in the world so well
01:18:45certainly there's
01:18:46um physical training protocols which are
01:18:48redefining what a 60 year old or 70 year
01:18:51could look like and feel like and be
01:18:54able to perform like why not do the same
01:18:57um so I don't think there's anything
01:18:59Supernatural or greedy about doing it I
01:19:02think that's the excitement of biology
01:19:04and neuroplasticity that you can extend
01:19:06it forward as opposed to just trying to
01:19:08wire up correctly during development
01:19:10this is a perfect time for me to ask you
01:19:13a question that I'd love a clear answer
01:19:15on if it's possible it's not always
01:19:18possible which is
01:19:19could you define 2020 vision and a few
01:19:23of the variants so that any person could
01:19:26understand it so we think of 2020 as
01:19:29perfect vision what does that mean what
01:19:32would degraded Vision look like
01:19:35whatever those numbers are and then what
01:19:38would above normal super normal vision
01:19:41look like yeah and is it true that
01:19:43fighter pilots have Supra normal vision
01:19:46yeah that's another population like like
01:19:48like many athletes of of people who may
01:19:52have sort of better than normal vision
01:19:542020 you know we Define almost
01:19:57everything we do based on you know kind
01:20:01of a average not sick human being adult
01:20:05whatever it is right and so 2020 Vision
01:20:08means that you can read the smallest
01:20:12letters at 20 feet away that the average
01:20:16healthy person can read
01:20:19at 20 feet away so you can read at 20
01:20:22what they can read at 20. okay now if
01:20:25you have worse than 20 20 Vision maybe
01:20:27you have 20 25 Vision 2040 Vision maybe
01:20:30you have 2200 Vision which on the eye
01:20:33chart at the office is like the Big E at
01:20:36the very top is 2200 Vision that means
01:20:40you can read at 20 feet what a normal
01:20:44person could read at 200 feet right so
01:20:48you've got pretty limited lower Vision
01:20:51we can measure down to like 2400 2800 at
01:20:56that point we're getting into like gosh
01:20:57can you count how many fingers I'm
01:20:59holding up you know that kind of thing
01:21:01and then ultimately hand motion can you
01:21:04even tell if my hand is moving in this
01:21:06side of your vision or this side of your
01:21:09and then ultimately after that light
01:21:11perception can you tell if the room
01:21:13lights are on or off right and that's
01:21:15kind of the edge of of being actually
01:21:17fully blind we call Legal blindness in
01:21:20the United States typically 2200 or
01:21:22worse and is it true that there are
01:21:24people who are legally blind that are
01:21:26out there driving as we're having this
01:21:28conversation I I have to imagine that
01:21:30that is unfortunately the case but it
01:21:33shouldn't be because those people
01:21:35obviously are really severely impaired
01:21:37and and that's obviously quite dangerous
01:21:39so so so that's 20 20. now
01:21:43it gets worse 2040 2080 20 100 can it
01:21:46get better yeah it turns out that people
01:21:49can be sort of on the other end of that
01:21:51curve and so we could have athletes and
01:21:53fighter pilots or people who have had
01:21:55LASIK surgery who are 2015
01:21:592010. if you're 2010 that means you can
01:22:03see it 20 feet what the average person
01:22:05needs to be only 10 feet away to see
01:22:07right and so you've got better than
01:22:10normal vision and people do get to that
01:22:12through a variety of ways and so it is
01:22:15possible to have better than 20 20
01:22:19does the degree of visual Acuity because
01:22:23that's really what we're talking about
01:22:24here differ dramatically between the two
01:22:28in most healthy people know
01:22:31um you know remember we talked about
01:22:33you're born with something like 2200
01:22:35Vision takes you a couple of years and
01:22:37it can be a little bit asymmetric 2200
01:22:39Vision yeah that reminds me um I've seen
01:22:42images of what babies can see you know
01:22:44parents love looking at their child and
01:22:46thinking their child is looking right
01:22:47back at them and indeed often the child
01:22:49is looking right back at them and your
01:22:51face to your child sorry to break this
01:22:53to you folks is incredibly blurry even
01:22:56at that close distance for probably the
01:22:59first six to eight months events before
01:23:00you come into sharp relief they're not
01:23:02seeing the fine details of your face
01:23:04yeah so smile big that's right smile
01:23:06break keep those eyebrows dark right and
01:23:08keep cooing at them because they can
01:23:10hear pretty well that's right yeah the
01:23:12Optics of newborn babies are just
01:23:13dreadfully bad yeah but they need
01:23:15visuals now other species not you know
01:23:21Raptors owls that hunt uh they can
01:23:25naturally have 2010 28 Vision right so
01:23:31much better vision and that's just their
01:23:33normal vision as best as has been
01:23:35measured so so there's definitely the
01:23:38potential for us to have better than 20
01:23:4120 Vision now all of this we call Visual
01:23:43Acuity and just to be clear for everyone
01:23:45that's the vision in the very center of
01:23:48your vision like when you're reading or
01:23:50looking that's the very center of your
01:23:53our vision is actually described
01:23:55variably as a hill of vision the peak is
01:23:58in the center that's let's say 2020 in
01:24:01most people right but it's it's normal
01:24:03to have that slope off and our visual
01:24:06Acuity your ability to read the eye
01:24:07chart on the edges of your vision if you
01:24:10can read the Big E that's pretty normal
01:24:12like you would be 2200 out on the edges
01:24:15of your vision and we would feel like
01:24:17yep that's pretty normal
01:24:19um so so our highest Acuity Visions in
01:24:22the center and that's a big part of why
01:24:23we spend a lot of time using those eye
01:24:25muscles to look around right we gotta we
01:24:27gotta get a little bit of a high Acuity
01:24:29view of what's around us uh fill in fill
01:24:32in the gaps of what our what our brain
01:24:35is is interpreting our peripheral world
01:24:37to look like it's almost like we have
01:24:39two visual systems we have a high Acuity
01:24:41High pixel density camera in the middle
01:24:44and then surrounding that is a pretty
01:24:46low resolution but very fast detector
01:24:49camera yes yeah yeah you mentioned Lasik
01:24:52but I want to make sure that before we
01:24:54talk about Lasik that we talk a little
01:24:55bit about contact lenses is there any
01:24:58detriment to having a piece of glass or
01:25:01a piece of plastic on the front of your
01:25:02eye all the time and the reason I ask is
01:25:04not because I think we should live
01:25:06necessarily exactly like our ancestors
01:25:08but it's a pretty bizarre adaptation
01:25:12to put a lens directly onto the front of
01:25:15the eye you have to imagine that the
01:25:16cells and tissues there are accustomed
01:25:18to getting a certain amount of oxygen
01:25:20they're accustomed to get a certain
01:25:21amount of interaction with the
01:25:23environment and and you also are now
01:25:25adding another surface the way that the
01:25:27tears are going to interact with the
01:25:30um you know with the cornea of the eye
01:25:31are probably changed and who knows maybe
01:25:33it doesn't make any negative difference
01:25:35at all but you know putting a contact
01:25:37lens on the front of the eye is you know
01:25:40about as close to putting a device on
01:25:42your brain as I can think of except for
01:25:44maybe the cochlear uh implant yeah yeah
01:25:48that's a great question now first of all
01:25:51um I want to distinguish uh there are a
01:25:54few really medical uses for different
01:25:58kinds of contact lenses like scleral
01:26:00contact lenses for people of certain
01:26:02diseases there are other kinds but I
01:26:04think what we really want to talk about
01:26:06right now is just kind of the
01:26:07run-of-the-mill I want to get my
01:26:09prescription taken care of but instead
01:26:11of wearing glasses I'm going to wear
01:26:14contacts even the newest generation
01:26:17contacts yes they sort of uh change the
01:26:22tier Dynamics on the surface of your eye
01:26:26um they decrease the oxygen you know
01:26:29diffusion that's just sort of out in the
01:26:31air onto the surface of our eye onto the
01:26:34cells that are on the surface of our eye
01:26:36but most of us especially as we're
01:26:40younger have enough tear film Reserve
01:26:43enough oxygen Reserve that we can easily
01:26:47tolerate these polymer gel soft contact
01:26:50lenses and and wear them happily the
01:26:54advantage of contact lenses over glasses
01:26:58purely from the perspective of
01:27:00correcting your vision is that there's
01:27:04different elements of of of of of the
01:27:08shape of your eye that need to be
01:27:10corrected if you need corrective lenses
01:27:12and so for example if you're for the
01:27:15basketball shape of your eye is a little
01:27:17too steep or a little too shallow that's
01:27:21what the standard glasses correct you
01:27:25may have been told that you have
01:27:26something called astigmatism that's
01:27:28where instead of having a basketball
01:27:30shaped eye you have a slightly football
01:27:32shaped die it's not round in the same
01:27:35dimensions on both axes and again
01:27:38glasses can correct that but then
01:27:40there's higher order aberrations in our
01:27:43corneas in the clear window in the front
01:27:45of our eyes or or to some degree in the
01:27:47lens inside the eye that are that are
01:27:49focusing the light that the glasses
01:27:51prescription can't correct but if you
01:27:54have a nice smooth contact lens on the
01:27:56front it can correct so a lot of people
01:27:58who wear glasses and contacts will
01:28:00report that they have a much higher
01:28:03quality of vision with their contact
01:28:05lens correction than with their glasses
01:28:07correction and again in service of
01:28:10enjoying the best Vision that you can
01:28:13enjoy in your daily life that's an
01:28:16upside to seeing if contacts could work
01:28:18Frio now there's another element though
01:28:21and that's like gosh is there a risk of
01:28:23contact lenses and especially as we age
01:28:28um we have less tear film reserves so
01:28:31contacts may become less tolerable as we
01:28:35and the other thing is being really good
01:28:37about the cleaning because you know the
01:28:39contacts can trap bacteria or fungus and
01:28:43if you get a corneal infection from a
01:28:46contact lens it actually can be quite
01:28:48devastating to your cornea even if you
01:28:50successfully treat the infection you can
01:28:52be left with some corneal scarring
01:28:53thankfully this happens very rarely but
01:28:57when it does happen it can be quite
01:28:58difficult on you know on the person
01:29:00thereafter to sort of suffer through
01:29:02having maybe a scar from that infection
01:29:05on the surface of their cornea that they
01:29:06that leads to some blurring vision for
01:29:09example so we always recommend that if
01:29:12you're going to wear contacts that you'd
01:29:14be really attentive to whether you're
01:29:16tolerating them well
01:29:17and then also to be really attentive to
01:29:20the recommended use and cleaning of the
01:29:22contact lenses I actually recommend that
01:29:25even though they're a little more
01:29:27expensive to afford that people should
01:29:29almost always be just using the daily
01:29:31contact lenses that they don't have to
01:29:34clean or use for you know two weeks or
01:29:37four week period so these are disposable
01:29:39contacts highly disposable and I hate to
01:29:41think of you know I don't know filling
01:29:43our oceans or what have you with uh more
01:29:45more more polymer plastic but at least
01:29:47the contact lenses are small and it's
01:29:49much safer for your eye to use a daily
01:29:52disposable than to use a two week or a
01:29:55four week and be responsible for the
01:29:57cleaning the other thing to be really
01:29:59responsible about is sleeping in them
01:30:02overnight because overnight when your
01:30:04eyelids are closed of course now you're
01:30:05getting even less oxygen to the surface
01:30:08of your eye actually most bacteria
01:30:10especially many of the Infectious
01:30:12bacteria to our bodies and to the
01:30:14surface of our eye are actually bacteria
01:30:17that Don don't really like oxygen and so
01:30:20we've got a low risk of getting
01:30:22bacterial infections on the surface of
01:30:24our eye but if we use contacts too much
01:30:27don't clean them or sleep in them
01:30:29overnight when our eyelids are closed
01:30:30and now there's even less oxygen kind of
01:30:32helping keep the surface more more clean
01:30:35if you will that increases the risk a
01:30:38lot so being really good with the
01:30:41recommended use and cleaning of the
01:30:42contacts is critical considering daily
01:30:45use contacts you don't have to and look
01:30:47most contacts are going to be the two
01:30:48week or four-week kind where you put
01:30:50them in the cleaning solution overnight
01:30:51each time give them a good rinse and put
01:30:53them back in the next day and again most
01:30:55people 99.99 some percent of people are
01:30:59going to do just fine with that follow
01:31:01the instructions and never get into
01:31:04as we age they're going to become less
01:31:06tolerable people are going to say I used
01:31:07to wear my contacts for 12 hours now my
01:31:10eyes feel really dry after six or eight
01:31:13maybe some years after that they say
01:31:15gosh I could barely use it for four
01:31:16hours I only use them when I go out on a
01:31:18Saturday night uh and and that's okay
01:31:21you can you can you can back off as you
01:31:23need to back off but in the meantime if
01:31:26it helps you especially in the younger
01:31:28decades if it helps you really enjoy uh
01:31:31Your Best Vision great
01:31:35what about UV protection in eyeglass
01:31:38lenses and or contacts
01:31:41I've dealt with many questions about
01:31:44blue light I am not somebody who
01:31:46believes that all blue light is terrible
01:31:47I think it's important to avoid Bright
01:31:50Lights of any wavelength late at night
01:31:52if you want your melatonin production to
01:31:54be normal and you want to sleep well it
01:31:55doesn't matter if you're wearing blue
01:31:57blockers or not if you're just under
01:31:58blastingly Bright Lights it's going to
01:32:00suppress your melatonin and yet some
01:32:02people enjoy blue blockers for that
01:32:04reason nowadays A lot of people wear
01:32:07glasses or blue blocking lenses or
01:32:09contacts throughout the entire day
01:32:11thinking that blue light is bad for our
01:32:13eyes during the day I happen to
01:32:15subscribe to the idea that we want as
01:32:16much bright light as we safely can
01:32:17tolerate during the day ideally from
01:32:20in order to set our circadian rhythm and
01:32:23yet a lot of eyeglasses and a lot of
01:32:25contact lenses out there have UV a and
01:32:29or UVB blocking features to them so what
01:32:31are your thoughts on this and I'm
01:32:32perfectly happy to be wrong and revise
01:32:34my my stance on this
01:32:37um yeah what what do you think about
01:32:38this UV a B blocking yeah it's a good
01:32:42it's it's a it's really important to
01:32:43distinguish that UV light on the light
01:32:46spectrum is right next to blue light red
01:32:49lights on the other end and of course
01:32:51infrared is beyond that and our eyes
01:32:54other animals can see these but our eyes
01:32:56can't see infrared that's why we call it
01:32:59Beyond red and we can't see ultraviolet
01:33:01we call it Beyond violet UV light is
01:33:05right next to Blue Light UV light is
01:33:08known to have a lot of adverse effects
01:33:12it's not really good for our skin and
01:33:15therefore you know we really want to
01:33:16avoid Sunburn and kind of UV data you
01:33:18know exposure and damage on our skin
01:33:20similarly it's not really good on our
01:33:22eyes and it affects both the ocular
01:33:24surface a little bit in terms of like
01:33:26kind of how dry or irritable your eyes
01:33:28might feel for some people and certainly
01:33:30over the long term UV light will
01:33:34accelerate the formation of cataract
01:33:36which is a blurring of an oxidative
01:33:39blurring of the lens inside the eye
01:33:41profound UV light can be damaging to the
01:33:44retina if you're getting way too much on
01:33:47so uh so blocking UV light I believe is
01:33:51just absolutely standard in every pair
01:33:55of eyeglasses and I don't know actually
01:33:58how much to what degree the different
01:34:00kinds of contact lenses also filter at
01:34:03least UV light now blue blockers blue
01:34:06blocking glasses is totally different
01:34:10as I say like I think almost all glasses
01:34:12because the Plastics almost all glasses
01:34:14are not made of glass anymore they're
01:34:16made of plastics but I think almost all
01:34:18of them now filter the UV light which
01:34:21again is like probably the safe move for
01:34:24our eyes and periocular environment
01:34:26around the eye environment
01:34:28so blue blockers you know that's been a
01:34:32huge fan I'll tell you the last three
01:34:33years through the pandemic everybody
01:34:35getting on their computer hours in front
01:34:37of Zoom meetings where we used to walk
01:34:39from building to building for a meeting
01:34:43um I you know I I remember you know like
01:34:46this sort of big uptick in these kinds
01:34:49of questions and I'm not sure that
01:34:52there's any data that blocking blue is
01:34:55helpful in any way and as you say it may
01:34:59actually play into sort of circadian
01:35:01entrainment of our natural daily Rhythm
01:35:04so so I think blocking UV is a good idea
01:35:07and I think it's pretty standard you
01:35:09know they make glasses is by the way
01:35:11that actually react to UV light they're
01:35:13called transitions there may be a few
01:35:15different brands I don't know uh but but
01:35:18you know these are the sunglasses that
01:35:20are clear except then they turn dark if
01:35:23you're out in the sunlight and it's not
01:35:25just any sunlight it's actually the UV
01:35:28wavelengths that that cause the chemical
01:35:31reaction in the glasses to turn from
01:35:33from Clear see-through to to sunglass
01:35:39you may notice if you if any of you out
01:35:41there are using these kinds of glasses
01:35:43uh that they don't work in the car
01:35:45you'll wear them in the car and they
01:35:47won't go to sunglasses even though it's
01:35:49sunny out and again that's because all
01:35:52standard car glass also filters UV
01:35:55that's why if you're riding around in
01:35:56the car and it's sunny out you've got
01:35:57your hand you know up next to the window
01:35:59uh wearing a t-shirt you never get a
01:36:02sunburn through the car window anymore
01:36:04because all our car glasses also
01:36:06filtering UV light for us so so that's a
01:36:10very informative answer and before we
01:36:12started recording you and I were
01:36:13discussing this practice of morning
01:36:15sunlight viewing which again I highly
01:36:17recommend over and over and you pointed
01:36:20out that low solar angle sunlight so
01:36:23sunlight low in the sky viewed for maybe
01:36:2610 minutes a morning and again not
01:36:27forcing oneself to look at it and stare
01:36:29but blinking as needed is not going to
01:36:32cause extensive UV damage to the eyes
01:36:34it's really the when the sun is directly
01:36:36overhead that we're getting a lot of UV
01:36:40which raises this other question which
01:36:42is for people that don't wear corrective
01:36:44lenses and therefore are not blocking UV
01:36:46light to the eyes
01:36:48um what should they do are they in
01:36:50trouble should they be wearing a brimmed
01:36:51hat brimmed Hat's a great idea that I've
01:36:54got a rid of a lot of the direct light
01:36:55into the eye of course you still have
01:36:57reflected light off of surfaces and that
01:37:00that can include UV light of course
01:37:03um you know wearing sunglasses outside
01:37:05even if you don't have corrective lenses
01:37:07you know it's may also be more
01:37:08comfortable to wear sunglasses outside
01:37:11um so so these are all fine you know
01:37:14at the end of the day it's probably not
01:37:16making a huge difference in the health
01:37:18of your eye whether you've spent the
01:37:20last 50 years wearing sunglasses really
01:37:22dogmatically for your outdoor time or
01:37:24not you know if you were going to
01:37:27develop let's just say age-related
01:37:29cataracts inside your eyes which
01:37:31we'll all get if we all live to 120 we
01:37:34all get cataracts you know it's going to
01:37:36happen some people younger some people
01:37:38older maybe if you were really dogmatic
01:37:40about wearing your UV blocking
01:37:42sunglasses maybe you'd get your your
01:37:44cataracts at 75 years old instead of 72
01:37:46years old it may not be a huge
01:37:48difference in that regard so again not
01:37:51something to be super stressed I think
01:37:53it's I think it's more a question of
01:37:54just what are you comfortable in uh and
01:37:57then certainly I will say the the other
01:37:58advantage of a wide brim hat is it's
01:38:01keeping sun off of your face and these
01:38:03are the you know some of the especially
01:38:05the upturned portions of your face like
01:38:07the cheeks and the nose these are the
01:38:08some of the most common places to get
01:38:10some of the skin cancers that you can
01:38:12get over a lifetime of sunlight exposure
01:38:15so you know the wide brain app is it's
01:38:17helping you for that as well
01:38:20can't help but ask about comfort
01:38:22at varying levels of brightness I'm the
01:38:25person that when sitting in a cafe or
01:38:27something and on a bright day I can be
01:38:29directly across from somebody like you
01:38:30who seems to be perfectly fine without
01:38:32sunglasses and maybe even more shaded
01:38:34under an umbrella or something of that
01:38:36sort and I'm squinting like crazy
01:38:38is it normal for there to be a pretty
01:38:41wide variation in sensitivity to light
01:38:43and does this have anything to do with
01:38:45the lightness or darkness of the eyes
01:38:47you have brown eyes I have green eyes
01:38:49but is there any real correlation there
01:38:51yeah you know it's a good question I
01:38:53don't know if it's been formally studied
01:38:54but I will tell you like I have the same
01:38:56impression you do which is that if you
01:38:59have uh blue eyes or light-colored eyes
01:39:02that you're more likely to have more
01:39:05sensitivity we know that there's
01:39:07differences in the iris muscles that
01:39:10constrict and dilate in response to
01:39:13for example when you go into your eye
01:39:16care provider and they're going to do a
01:39:17dilated exam and they put the eye drops
01:39:19in your eye that dilate the eyes they
01:39:21sort of change the the nerve impulses
01:39:24onto the iris muscles of the iris
01:39:26dilates and you get those big big open
01:39:31um people with blue eyes we absolutely
01:39:33know blue or Hazel or light colored eyes
01:39:36uh you put that eye drop to dilate there
01:39:38rise it's going to last four six eight
01:39:41hours whereas in a brown-eyed person
01:39:43often the dilation only lasts one two
01:39:45four hours so there's clearly biological
01:39:49differences between the irises and their
01:39:52muscles and maybe the nerves that feed
01:39:53those muscles uh between light-eyed
01:39:56people and and darker eyed people and
01:39:59that may also therefore relate to this
01:40:02differential sensitivity that some
01:40:04people have you know if you're not able
01:40:06to constrict your eyes in the bright
01:40:08light as effectively you're going to
01:40:10find that bright light more frustrating
01:40:13more annoying uh you know even painful
01:40:16people will feel like their eyes are
01:40:17cramping almost as they try to get that
01:40:20those eye muscles to activate to bring
01:40:23down the pupil and block some of that
01:40:25excess light from getting in interesting
01:40:28yeah let's go back to Lasik what is
01:40:32should I get Lasik eye surgery does it
01:40:35does everyone need Lasik can it help
01:40:37every can it make us you know
01:40:38suprophysiological you know can it make
01:40:40me a 2010. you know often it can I'll
01:40:43just say that you know right up front it
01:40:45is amazing people will come out of Lasik
01:40:48surgery uh better than 2020 but uh the
01:40:52cornea we talked about before that's the
01:40:54Clear Window on the front of your eye
01:40:56all the light has to get through there
01:40:57and we talked about before already like
01:40:59if your cornea is misshapen if the
01:41:01basketball shape of it is too too
01:41:04shallow or too steep then you're going
01:41:06to need glasses to see a distance and
01:41:08also at near if it's to football instead
01:41:11of basketball then it's going to be what
01:41:13we call astigmatism and uh and then you
01:41:16can't you need a correction for that
01:41:18instead of correcting with glasses that
01:41:21sort of help shape the light so it can
01:41:24go through your slightly off-shaped
01:41:26cornea instead of wearing contact lenses
01:41:29which also shape the light just as it's
01:41:31entering your cornea right on the
01:41:33surface of the eye you can just reshape
01:41:37and the way Lasik does that there's a
01:41:40few different versions of Lasik but
01:41:42basically the way the Lasik does that is
01:41:45it actually ablates or uh gets rid of a
01:41:50little ring or rim of that corneal
01:41:54so that for example if you were a little
01:41:57shallow and you got rid of a little bit
01:41:59of that tissue around the edge with the
01:42:02laser the Lasik you know starts with the
01:42:04word laser if you got rid of that edge
01:42:07tissue then you're sort of making it a
01:42:08little more basketball shaped right or
01:42:10if you were too steep on your cornea and
01:42:13you used the laser to kind of shave off
01:42:15a little bit of the the tip of that
01:42:17basketball right then you're flattening
01:42:19it out flattening out the cornea so it's
01:42:21that kind of reshaping and the
01:42:23technology has come so far that the
01:42:28Lasik procedures can actually correct
01:42:31not just the regular aberrations that we
01:42:34talked about but also some of these
01:42:36higher order aberrations and there are
01:42:39different monikers for this kind of
01:42:40Lasik it's all I think become fairly
01:42:42standard but wave front guided where
01:42:45it's actually using light waves to
01:42:47measure with a very exact localization
01:42:50exactly how much and where to laser for
01:42:53each individual eye to make that cornea
01:42:56pass the light as ideally as possible
01:42:58now one or a few percent of patients
01:43:01will actually have a dry eye problem so
01:43:04after a Lasik because so it does
01:43:06interfere a little bit with those
01:43:07corneal nerves for example and I and I
01:43:10do think that if you're a person who
01:43:12already has dry eye hopefully if you're
01:43:15asking your eye surgeon about Lasik
01:43:17hopefully you're being counseled that if
01:43:20you have dry eye this might not be a
01:43:22good idea for you just like contacts
01:43:24might not be a good idea for you if you
01:43:26already have a lot of dry eye but for a
01:43:28lot of people especially a lot of
01:43:30younger people it's quite common I I
01:43:31think the statistics suggests maybe 15
01:43:33or 20 percent of people who would
01:43:36benefit from LASIK you know who who
01:43:38would who would otherwise be wearing
01:43:40glasses may get Lasik at some point in
01:43:43um you know I used to joke
01:43:46you know Lasik it costs more money than
01:43:48a pair of glasses but
01:43:50it doesn't cost more money than 10 pairs
01:43:53of prescription glasses over the course
01:43:55of a decade or two you know and so I
01:43:58used to joke that gosh if uh if everyone
01:44:00had to have laser eye surgery for their
01:44:04and someone came along and said hey I've
01:44:07got an invention you don't have to have
01:44:09laser eye surgery anymore it rests on
01:44:12the ears and the bridge of your nose I
01:44:14call them glasses could they have sold
01:44:16those for a thousand two thousand
01:44:18dollars a pair I don't know maybe but
01:44:20you know there's kind of a cultural
01:44:22element of saying you know like I don't
01:44:24want to wear glasses you know I'd love
01:44:26to be able to walk around without
01:44:27relying on glasses or contacts of course
01:44:29people are very athletic or spending a
01:44:32lot of their time doing Athletics they
01:44:33may be quite irritated to have to deal
01:44:35with glasses or contacts people who have
01:44:38very severe prescriptions I mean if you
01:44:40wake up and you can't even really you
01:44:42know you're fumbling for your glasses on
01:44:44the bedside table because you have such
01:44:46a strong strong prescription you can't
01:44:49even see what it says on the alarm clock
01:44:51next to the bed you know these are all
01:44:54groups of patients who like really
01:44:56change their daily lives by getting out
01:44:58of glasses or contacts and taking
01:45:01advantage of Lasik and in I don't know
01:45:0399 of the time it's going to be like a
01:45:06safe comfortable outcome for the patient
01:45:08do they do Lasik on kids
01:45:12um there are certain conditions uh
01:45:15unusual cordial conditions where
01:45:17procedures like Lasik get used but I
01:45:19believe uh it's ideal to not do it on
01:45:23children uh or even even young teenagers
01:45:27and the reason goes back to what we were
01:45:29talking about before you are much more
01:45:31likely to change the shape of your eye
01:45:34and therefore the prescription you need
01:45:37and therefore what exactly the Lasik
01:45:39would laser while you're still in those
01:45:42growing years and you really want to be
01:45:44able to say hey my eyeglasses
01:45:47prescription has not changed in the last
01:45:49two or three or five years because if
01:45:52you do Lasik and then your eye keeps
01:45:55changing shape then by the next year all
01:45:58of a sudden the lasik's not doing you're
01:46:00backing glasses again right you can do a
01:46:02touch-up Lasik do a little bit more but
01:46:05it's generally you know you're going to
01:46:06be a happier person if you've reached
01:46:09that point in your life and maybe that's
01:46:11maybe that's your late teens more
01:46:13commonly it's into the 20s where your
01:46:15eye has stopped changing its
01:46:17prescription every year you've been
01:46:19steady and stable for some years and now
01:46:22you do the Lasik and it could easily
01:46:24last you a decade
01:46:26you mentioned dry eye
01:46:28get a lot of questions about dry eye and
01:46:31a few years ago I think you and I were
01:46:33at a meeting and someone
01:46:34who is very woven in with the companies
01:46:39build and test drugs for different
01:46:42aspects of vision health said you know
01:46:45what the field really needs is a
01:46:48treatment that works for dry eye and I
01:46:50thought dry eye like of all things like
01:46:52why dry and then the more I learned
01:46:53about it I realized that there are
01:46:55millions and millions of people that
01:46:57really suffer from dry eye and for whom
01:47:00standard drops are just not working so
01:47:03what underlies dry eye is it some
01:47:05deficiency in the lacquer hormone glands
01:47:06that produce tears for the eye and and I
01:47:09think of Tears as just kind of salty
01:47:11and I wonder if they are more than that
01:47:14is there an oil in there and if we know
01:47:17what's in tears why can't somebody just
01:47:19manufacture something that works as well
01:47:21as tears yeah you know it turns out you
01:47:24know we we've got a lot of other eye
01:47:28but by far the most common eye disease
01:47:32and and I've been told by far the most
01:47:35common eye treatment you know purchased
01:47:38by anyone now granted it's almost always
01:47:40over the counter things like artificial
01:47:42tears is for dry eye
01:47:44and uh in part that's because as we age
01:47:49tier quantity goes down and our tier
01:47:52quality goes down and so what do those
01:47:56we have two different major elements to
01:47:59tiers and as you alluded to one is the
01:48:02salt water porn of part of the tears and
01:48:05those are made primarily by the lacrimal
01:48:07gland and there's a steady drip of those
01:48:09tears onto the ocular surface as well as
01:48:11reflexive tearing right if you get an
01:48:13eyelash in your eye or or you cry your
01:48:16lacrimal ground will actually squeeze
01:48:18out extra salt water tears uh onto the
01:48:21surface of the eye and so so that's
01:48:23that's where most of the sort of wet
01:48:25part is coming from but there's also
01:48:28essential oils critical oils these come
01:48:31from other types of glands including
01:48:33glands in our eyelids called meibomian
01:48:35glands and the oils form a surface over
01:48:40the salt water part of the tear film
01:48:44and and also intermix into the tears and
01:48:48as we age we go down in the quantity of
01:48:52both salt water part of our tears and
01:48:55oil part of our tears but also the
01:48:57quality and in particular the oil parts
01:49:01uh can often be seen to be going down
01:49:05the the eye drop industry has pretty
01:49:10much solved for replacing the salt water
01:49:13part of your tears right you can get
01:49:16either bottles of preserve preservative
01:49:19containing you know you could use that
01:49:21bottle all month or for a month or two
01:49:23or you can buy these strips of
01:49:25preservative free artificial tears which
01:49:28are really basically like the salt water
01:49:30components and you can use those
01:49:32preservative free ones we have patients
01:49:34using them every hour if they need to
01:49:37right you're not going to hurt anything
01:49:38with preservative free artificial tears
01:49:40you just drop them in just drop them in
01:49:42yeah either I as as often as you want or
01:49:44need when you feel it it's exacerbated
01:49:48in the world we live in uh
01:49:51especially these days now with more time
01:49:54on computer it turns out that when you
01:49:56read including when we maybe used to
01:49:59read more books than we do now but also
01:50:01read on the computer or stare at the
01:50:03computer screen or work on the computer
01:50:04or actually just even watch the TV
01:50:07I've done very careful studies you blink
01:50:10less when you're doing any of those
01:50:14and when you blink glass you're
01:50:15redistributing the tears less
01:50:18effectively and you're squeezing out
01:50:21less of the tears including less of the
01:50:23oils as effectively as you could be when
01:50:26you're blinking and so
01:50:29um so between aging tier quality tier
01:50:33a lot of our activities
01:50:35we're kind of in this losing proposition
01:50:38now now I mentioned that uh we're pretty
01:50:40good at replacing the wet salty part of
01:50:42our tears but actually as an industry we
01:50:45haven't really figured out a
01:50:47how to really effectively replace the
01:50:50oily part and the oils do a few things
01:50:52including when you have a layer of oil
01:50:55on top of a layer of water
01:50:57the water is less likely to evaporate
01:51:00and so the oils help hold the tears on
01:51:03the surface of your eye and so if we're
01:51:04not making as many or as good oils as
01:51:07part of our tear film that's uh that's
01:51:10also like kind of working against the
01:51:12salt water part of our tears
01:51:15um so yeah as an industry as a community
01:51:18uh that we haven't really figured out
01:51:20how to get the oil part solved for
01:51:23either by effectively replacing the oils
01:51:28treating our eyelids in a way kind of
01:51:30rejuvenating those oil glands getting
01:51:33them to kind of go back to their
01:51:34youthful State again you know so that
01:51:36the eyes including the eyelids and the
01:51:39oil glands unfortunately they're aging
01:51:40just like the rest of our body so so
01:51:43this is this this is one of the major
01:51:45features uh is uh is dry eye and and uh
01:51:49and it's tough on patients because you
01:51:51feel it it's really tough because you
01:51:53feel it yeah I have yet another
01:51:56experience to report where when I had
01:51:59the blepharitis which fortunately was
01:52:01transient I also experienced it every
01:52:03time I would blink I could feel the
01:52:04blink and boy I'll tell you I we all
01:52:09most of us take for granted uh what a
01:52:12pleasure it is to not observe the
01:52:14blinking of our eyes because for those I
01:52:17think in last about two weeks every time
01:52:19I blink I'd feel an almost sandpaper
01:52:21like experience it wasn't particularly
01:52:23painful but it was very uncomfortable
01:52:25because it suddenly conscious of every
01:52:27blink and it's very very distracting now
01:52:29that resolved when the blepharitis
01:52:31resolved but I can't even imagine what
01:52:33it would be like to deal with that all
01:52:35day long every day yeah really Dreadful
01:52:37yes it really is and it and so you're
01:52:40absolutely right it's a very it's one of
01:52:42our really big unmet needs and and
01:52:44although for most people with dry eye it
01:52:47can be managed with just the regular
01:52:49over-the-counter artificial teardrops
01:52:51you can buy at the grocery store or over
01:52:53the counter at the pharmacy for a subset
01:52:56of people who have really much more
01:52:57severe symptoms with the dry eye it's
01:53:00it's really it's hard it's a really hard
01:53:02thing to have to live with all the time
01:53:03and and we Counsel on the use of Tears
01:53:06we Council on the use of eyelid cleaning
01:53:09like we talked about before where you
01:53:10take either these eyelid scrubs or a
01:53:12little dilute baby shampoo to keep those
01:53:14eyelashes really clean that keeps those
01:53:17oil glands functioning at their top
01:53:19capacity for you uh so that you're
01:53:21maximizing you know high quality cheer
01:53:23production reducing inflammation is also
01:53:26important whether that's inflammation
01:53:28from allergy and of course a lot of
01:53:29people's dry eye gets much worse in the
01:53:32spring with seasonal allergies when
01:53:34pollen is around if you have dust
01:53:36allergies in your home uh that worsens
01:53:40your symptomatic dry eye
01:53:43or other forms of inflammation there's a
01:53:45there's an element of dry eye that we
01:53:47actually think is
01:53:49inflammation kind of working against our
01:53:51tear glands and and in fact some of the
01:53:54prescription drops now to help combat
01:53:56more severe dry eye uh are
01:53:59anti-inflammatory or even low-dose
01:54:01steroid types of eye drops
01:54:04um so I think these are all uh sort of
01:54:06Next Generation treatments I think at
01:54:08the at the really Leading Edge of Next
01:54:11Generation treatment is trying to better
01:54:12understand the nerves on the cornea and
01:54:16ocular surface and if there are ways
01:54:18that we could better treat them and help
01:54:19help regenerate and rejuvenate kind of
01:54:22how the nerves and the and the tissue
01:54:25cells are interacting underneath that
01:54:27tear film and that's where for some
01:54:30patients we can actually use either for
01:54:32example blood serum your blood serum is
01:54:34actually very rich in growth factors
01:54:38and many of those growth factors it
01:54:40turns out empirically are really helpful
01:54:43for people with dry eye so if you're one
01:54:46of those people who's been really
01:54:47struggling with with dry eye you might
01:54:50ask your eye care provider hey I heard
01:54:52about serum tears is that something that
01:54:54could help me serum tears because this
01:54:57PRP is this platelet-rich plasma related
01:54:59but but not the plate platelet-rich
01:55:02portion at least not yet they can draw
01:55:05your blood spin out all the cells you're
01:55:07left with the kind of liquid part of
01:55:09your blood that's the serum and then
01:55:11they can dilute that with some salt
01:55:13water maybe with some preservatives in
01:55:15some cases yeah you could keep it in
01:55:17your freezer thaw a bottle when you're
01:55:19ready to use it you know each few weeks
01:55:21and and then use it just like an
01:55:23eyedropper bottle and those serum tears
01:55:26uh actually can be very helpful for
01:55:28people with with much more advanced or
01:55:30severe hard to control dry eye symptoms
01:55:33uh companies are really trying to figure
01:55:36out hey what are the most important
01:55:38parts of the the serum can we just
01:55:40identify and package just the growth
01:55:43factor and uh and turn that into a
01:55:46product for dry eye patients and so
01:55:48there's a lot of research on the ocular
01:55:50surface and dry eye uh going into
01:55:54um going into that space right now I'll
01:55:56tell you the one other recommendation
01:55:57that I always give patients
01:56:00there's a fair amount of evidence that
01:56:03if you're getting too much of some of
01:56:05these preservative chemicals which of
01:56:08course if you're going to use an eye
01:56:09drop bottle for a month it should have a
01:56:11preservative in it right so that you
01:56:13know open the bottle and then it grows
01:56:15bacteria a couple weeks later and now
01:56:16you're you're you know you're using
01:56:18contaminated eye drops so for bottles
01:56:22it's typical to have preservatives but I
01:56:24really recommend for patients if they're
01:56:26using anything more than a couple drops
01:56:28here and there for their dry eye control
01:56:30to actually go for one of the
01:56:32preservative free artificial tears they
01:56:35come in lots of Brands I'm sure the
01:56:37house brands at any of the pharmacies
01:56:39use them too I make them too and these
01:56:41are the ones that come in like strips
01:56:43plastic strips and you break one off you
01:56:46break off the little cap you can use as
01:56:48much as you want all day you have to
01:56:50throw that one out if you have anything
01:56:52left over you have to throw it out at
01:56:54the end of the night and the next day
01:56:55break off a new one because there's no
01:56:57preservatives and once you open it you
01:57:00don't want bacteria to grow in that salt
01:57:02water right but it's really good because
01:57:05the preservatives can be very irritating
01:57:07or even inflammatory to the ocular
01:57:09surface to the surface of our eyes so we
01:57:12really do want to if we're using more
01:57:14than a drop or two
01:57:16upgrade that cost a little bit more
01:57:17money if they're still over the counter
01:57:19upgrade yourself to the preservative
01:57:21free artificial tears those are great
01:57:23recommendations I'm also really
01:57:26interested in this serum
01:57:28thing uh because you know we're this
01:57:31discussion taking place 10 years ago and
01:57:34I raise PRP platelet-rich plasma there
01:57:38would probably be a lot of eye rolls no
01:57:39pun intended because I think myself and
01:57:42a lot of other people in the let's call
01:57:43the sort of standard scientific and
01:57:45medical community looked at
01:57:46platelet-rich plasma right alongside
01:57:48stem cell therapies because they were
01:57:50cheek to jowl back then as you recall
01:57:51before the FDA regulations about stem
01:57:53cell claims which we will get to
01:57:57PRP was suggested as a source of stem
01:58:00cells it turns out there are very few if
01:58:02any true stem cells in PRP and yet now
01:58:04as I understand it PRP is an FDA
01:58:07approved protocol for injection into the
01:58:11uterus injection into pretty much every
01:58:15tissue and organ system of the body in
01:58:17order to quote unquote rejuvenate it and
01:58:20here I'm not promoting PRP and yet it is
01:58:22a very common practice now in more
01:58:24standard medical clinics but it started
01:58:26off kind of Niche even gray Market kind
01:58:28of underground it's diverged from stem
01:58:30cell therapies and we're going to talk
01:58:32about major modes of vision loss in a
01:58:35and this horrible situation that
01:58:38happened down in Florida of a clinic
01:58:39injecting stem cells into patients eyes
01:58:41to recover vision and it actually
01:58:43blinded them so we'll talk about stem
01:58:46cell therapies but for the record is PRP
01:58:49something that's now standard in major
01:58:51optimal ophthalmic clinics excuse me
01:58:54including your department at Stanford
01:58:57are you drawing out blood spinning it
01:58:59down taking plasma taking serum and
01:59:02re-injecting it or reapplying it to
01:59:04patients eyes not not yet in
01:59:06Ophthalmology uh in eye clinics I I
01:59:09would say we're sort of like right now
01:59:10on the edge of uh groups are starting to
01:59:13study that is it safe is it valuable is
01:59:16it any better for certain conditions
01:59:18like on the ocular surface than serum
01:59:20Tears For example this sort of diluting
01:59:23a patient's own own blood serum uh so so
01:59:26it's being studied it's a very active
01:59:28area now it turns out that this PRP
01:59:31plasma has uh you know again like a high
01:59:35concentration nation of growth factors
01:59:37that's probably what's responsible for a
01:59:39lot of the kind of quote tissue
01:59:41Rejuvenation effects uh be that be they
01:59:44as they may but but it's being studied
01:59:47but it's definitely not a standard of
01:59:49care yet uh at least in in Ophthalmology
01:59:52space and and you know I think whenever
01:59:55there's something really new it really
01:59:57deserves to be properly studied we
01:59:59talked before about you know at first
02:00:01you're going to do trials where you just
02:00:03test it carefully in a few people maybe
02:00:05a few of the most severely effective
02:00:07affected patients be really thoughtful
02:00:10about uh you know the ethics of trying
02:00:12out for safety then as you develop a
02:00:15little understanding of the safety you
02:00:17really want to eventually get to
02:00:19properly controlled randomized what
02:00:21people in the community often call
02:00:23double blind trials but we in
02:00:24Ophthalmology like to call Double masked
02:00:26trials blind is a bad word
02:00:29trials yeah yeah so you really want
02:00:32properly controlled trials testing is it
02:00:34really working thing is it really
02:00:37deserve the claims that people are
02:00:39making and that has not yet really come
02:00:42to fruition at that level for
02:00:44Ophthalmology or Eye Care yet so we've
02:00:46been talking a lot about normal visual
02:00:48development eye checks and some of the
02:00:51more typical challenges that people have
02:00:54with their vision
02:00:55but we haven't yet touched on some of
02:00:57the really debilitating stuff
02:01:00things like glaucoma things like
02:01:03retinitis Pigmentosa macular
02:01:05degeneration the things that if we could
02:01:08we would all avoid and yet are out there
02:01:11in the world at pretty high rates you
02:01:14know I'm sure you'll share with us what
02:01:17and as bad as these things are there are
02:01:20ways to detect and offset their
02:01:23progression so that people don't
02:01:24necessarily lose their Vision so if you
02:01:27could could you share with us what are
02:01:29the major forms of vision loss in
02:01:31childhood and in adulthood and what can
02:01:34each and all of us do in order to find
02:01:37out if we have one of these conditions
02:01:39and therefore treat it effectively yeah
02:01:41that's great you know
02:01:43let's start by just
02:01:46reminding ourselves what are the major
02:01:47causes of vision loss and these are
02:01:50going to differ where you are in the
02:01:53but the major the number one cause of
02:01:55low vision is actually refractive error
02:01:58people who need glasses and especially
02:02:02in other countries affordability access
02:02:05can't even get glasses okay so that's
02:02:08just refractive error but that's
02:02:10fundamentally correctable
02:02:13the next most common cause of vision
02:02:15loss is cataract cataract is the
02:02:19blurring the Aging of the lens inside
02:02:22the eye behind the cornea we talked
02:02:24about how that is responsible for
02:02:26focusing light under the back of the eye
02:02:28it also has to be clear enough that the
02:02:29light gets through the lens
02:02:31and a cataract is a normal aging process
02:02:34you know as I said if we all live to 100
02:02:36or 110 years old we'll all get cataracts
02:02:39we'll all need cataract surgery we
02:02:41actually is you know in in the eye
02:02:43clinic we see cataracts years or even
02:02:46decades before they're affecting your
02:02:48vision in a meaningful way so that the
02:02:51cataracts are forming and that's okay
02:02:53but at some point they get bad enough
02:02:55that it's time to take them out we've
02:02:58actually solved for cataract surgery
02:03:00pretty efficiently we could do a four to
02:03:04eight minute surgery maybe if we're
02:03:06taking our time it's 10 or 12 minutes of
02:03:09surgical time take out a cataract it
02:03:12works beautifully 99 point something
02:03:15percent of the time we put a plastic a
02:03:17clear plastic lens inside the eye
02:03:20exactly where your lens used to be and
02:03:23there's even lenses that can Flex or
02:03:26focus light from far and near so
02:03:28cataracts is fundamentally a there's
02:03:30still room for improvement but there's
02:03:31it's fundamentally a solved problem the
02:03:35problem is is that worldwide there
02:03:38aren't enough cataract surgeons there's
02:03:40not access to care the Machinery or the
02:03:44cost too much money in developing
02:03:48countries to get out to the number of
02:03:50people who would need them so it's
02:03:52actually just again an access to care
02:03:54cataract is a reversible treatable
02:03:57easily treatable problem
02:03:59but it's number two on the list of
02:04:02causes of vision loss in the world
02:04:04because we don't have enough access to
02:04:06care we need a lot more sort of
02:04:07programming around Global Ophthalmology
02:04:09Global Eye Care to solve for cataract
02:04:12just to bring that solution to countries
02:04:17then after that you start hitting the
02:04:20eye diseases that lead to what are
02:04:23currently irreversible
02:04:25non-reversible causes of vision loss the
02:04:29number one cause of irreversible vision
02:04:32loss in the world is glaucoma
02:04:35so what is glaucoma glaucoma is actually
02:04:37probably a little cluster or
02:04:39constellation of diseases that we lump
02:04:41together it's a degenerative disease
02:04:45like a neurodegeneration we talk about
02:04:47neurodegenerations in the brain like
02:04:49Alzheimer's and Parkinson's glaucoma is
02:04:51a neurodegenerative disease it happens
02:04:54instead of affecting one or different
02:04:56area in your brain it happens to affect
02:04:58the optic nerve that connects the eye to
02:05:01the brain and we need our optic nerves
02:05:03to carry all the visual information from
02:05:05the eye to the brain and so if your
02:05:07optic nerve is degenerating in glaucoma
02:05:10and I should add there are other optic
02:05:12neuropathies so-called diseases of optic
02:05:16nerve degeneration for example you can
02:05:17get a stroke of the optic nerve you can
02:05:20have an inflammatory disease like
02:05:22multiple sclerosis called optic neuritis
02:05:25that affects the optic nerve so you can
02:05:27get other optic nerve diseases but
02:05:30glaucoma is by far the most common optic
02:05:32neuropathy and the problem is is just
02:05:34like you know just like spinal cord
02:05:36injury which is also part of the central
02:05:39nervous system right the brain the
02:05:41spinal cord the rat and the optic nerve
02:05:42that's the central nervous system and
02:05:44there's no regeneration and that's why
02:05:46spinal cord injury leads to permanent
02:05:48paralysis well optic nerve injury or
02:05:51optic nerve degeneration unfortunately
02:05:53leads to permanent vision loss so in the
02:05:56case of glaucoma how do we get ahead of
02:05:59glaucoma has two major risk factors one
02:06:03is increasing age there are actually
02:06:06infantile and pediatric glaucomas
02:06:08unfortunately and those can be much more
02:06:11aggressive much more damaging when they
02:06:13present so early in kids uh in babies
02:06:18most of the kind of run-of-the-mill
02:06:20glaucoma usually results presents in
02:06:22adulthood and even in in the Aging
02:06:24adults so much more common after 50 or
02:06:2660 or 70 years old increasing the other
02:06:30main risk factor for glaucoma is
02:06:32increasing eye pressure the eye actually
02:06:34you know it stays inflated it's a
02:06:36balloon it has to stay inflated we need
02:06:38some amount of eye pressure to keep our
02:06:40eye as a as an inflated balloon but if
02:06:43the eye pressure goes too high and we
02:06:46talked about this before you won't even
02:06:48feel it if it slowly gets too high if
02:06:51the eye pressure goes too high that
02:06:53causes glaucoma and
02:06:56um and that's one of the things that we
02:06:58talked about you really include in a
02:07:00comprehensive eye exam when you're just
02:07:03getting a screening checkup at your eye
02:07:05care provider at your optometrist or
02:07:07ophthalmologist office they're going to
02:07:08check your pressure and just as a
02:07:10screening tool check to make sure it's
02:07:14we can treat glaucoma today
02:07:17by trying to reduce the impact of that
02:07:20high pressure by lowering the eye
02:07:22pressure so we have treatments for
02:07:24glaucoma that Target the eye pressure we
02:07:27have medications like eye drops we have
02:07:29lasers that can be used inside the eye
02:07:32that can also lower the eye pressure and
02:07:35ultimately if we need them we also have
02:07:36surgeries that can also provide an
02:07:39outflow that lets the fluid out of the
02:07:41eye in a controlled way so that the eye
02:07:44pressure can be brought back down into
02:07:48again the reason that glaucoma
02:07:51ends up being the number one cause of
02:07:54irreversible blindness in the world is
02:07:58we can't get those therapies everywhere
02:08:01in the world the affordability of eye
02:08:03drops the access to lasers or surgical
02:08:06procedures Around The World Isn't equal
02:08:08to what it is here and even within our
02:08:11country you know people may not be
02:08:13accessing Health Care effectively to get
02:08:16screened for glaucoma or to get treated
02:08:18for glaucoma the other big problem with
02:08:20glaucoma is that it affects our
02:08:22peripheral vision first and only very
02:08:26late in the disease does it pinch in and
02:08:29finally pinch off the center of our
02:08:31vision in typical glaucomas
02:08:34and that's a real problem because
02:08:36we don't notice if our peripheral vision
02:08:39is down you know our peripheral vision
02:08:41isn't that good to begin with and if
02:08:44you're driving and you can see a
02:08:45pedestrian step off the sidewalk you
02:08:48think your peripheral vision is fine but
02:08:50actually your peripheral vision could
02:08:52already start being damaged by glaucoma
02:08:55and you won't notice it in regular daily
02:08:57life and that's where the importance of
02:08:59screening and early detection really
02:09:02comes in for glaucoma
02:09:05what we don't have for glaucoma we can
02:09:07come back to like kind of what's The
02:09:09Cutting Edge of the future in these eye
02:09:11diseases what we don't have are
02:09:12treatments that really Target the optic
02:09:15nerve degenerative process and we can
02:09:18come back and talk about that
02:09:20so that's glaucoma and optic
02:09:22neuropathies then the next two major
02:09:25causes of currently largely irreversible
02:09:30vision loss our age-related macular
02:09:35and then diabetic retinopathy now
02:09:39age-related macular generation is just
02:09:42like it sounds major risk factors age
02:09:45it's very common and actually in the
02:09:47developed world you know countries that
02:09:50are more developed also countries that
02:09:51have a larger Caucasian white population
02:09:54it's more common in certain populations
02:09:58um it actually is you know definitely a
02:10:01leading cause of vision loss in the
02:10:03elderly population for example in the
02:10:07um and uh there's two forms of macular
02:10:11degeneration but they both end up
02:10:14targeting the same part the same part of
02:10:17the retina and the part of the retina is
02:10:19really like the rods and the cones that
02:10:21we talked about before the rods do your
02:10:23low light vision at night time primarily
02:10:27your cones do color vision and bright
02:10:29light you know sort of normal lighting
02:10:31that we experience you know through most
02:10:35and in that back of the retina you can
02:10:38have what's called dry macular
02:10:40degeneration which is a slow thankfully
02:10:44slow but slow Insidious disease that
02:10:47causes the degeneration of the rods and
02:10:50cones and also the support cells that
02:10:53help feed the rods and cones and take
02:10:55care of the rods and cons they're called
02:10:56rpe cells retinal pigment epithelium
02:10:59it's not really critical of course the
02:11:02names of every different cell type but
02:11:04these are like the the the light
02:11:06collecting cells in our eyes in the
02:11:08retina and they degenerate in macular
02:11:10degeneration and in the dry form there's
02:11:13this slow degeneration but some percent
02:11:16of people with the dry form of macular
02:11:18generation will actually convert to
02:11:19What's called the wet form it's called
02:11:22wet because new blood vessels actually
02:11:24grow inappropriately under and even into
02:11:28the retina and new blood vessels unlike
02:11:31our mature blood vessels tend to be
02:11:33leaky and so now the flu fluid leaks out
02:11:36of those blood vessels gets into the
02:11:38retina interferes with vision and that
02:11:40can lead to a much more acute loss of
02:11:43vision now we have some treatments for
02:11:47wet macular degeneration we have
02:11:49injections that can go into the eye that
02:11:51actually fight against the molecules
02:11:54that are causing those new blood vessels
02:11:56to grow and these are antibodies that
02:11:59can be injected into the eye and they
02:12:00can be very effective controlling
02:12:02patients wet macular degeneration
02:12:06it's been a much bigger uphill battle
02:12:08even over the last decade as advances
02:12:11are being made to to really try to knock
02:12:13back or or slow down even the dry form
02:12:17of macular degeneration there was just
02:12:20some exciting news even just in the last
02:12:22few months the first uh successful
02:12:26Trials of a treatment for the dry form
02:12:30uh have just shown success and properly
02:12:32randomized controlled human clinical
02:12:35trials phase three clinical trials so
02:12:37it's an exciting time
02:12:40those new treatments are not going to be
02:12:42a Panacea they slow the progression like
02:12:45the an anatomic progression of the
02:12:49uh maybe by 20 or 25 so so patients are
02:12:53still going to get worse even with those
02:12:55treatments so there's still a lot more
02:12:56to be done to really knock back macular
02:13:00degeneration I want to mention you
02:13:02mentioned retinitis Pigmentosa that's
02:13:04like an inherited form of a type of
02:13:08macular degeneration it's also affecting
02:13:10the rods and cones and also the support
02:13:12cells the rpe cells in the back of the
02:13:15eye retinized Pigmentosa is an inherited
02:13:19there are actually many different genes
02:13:22you could have that could leave to
02:13:23retinized pigments Pigmentosa in
02:13:26aggregate if you add up all the people
02:13:28with all those different genes uh and it
02:13:31can be very devastating because it can
02:13:34really affect the vision knock out your
02:13:35vision very early in life including in
02:13:37children and even versions of that and
02:13:40babies but you add that all up it's
02:13:42still much less common in aggregate than
02:13:44macular degeneration
02:13:46but in a way it's you know quite a bit
02:13:48more severe because it does affect
02:13:50people much earlier in life so so I sort
02:13:53of Clump those together macular
02:13:54degeneration retinitis Pigmentosa
02:13:56degeneration of the rods and cones and
02:13:59the support cells the rpe support cells
02:14:02and then you you can't have this part of
02:14:05the discussion about what are the
02:14:06devastating eye diseases without
02:14:07bringing up diabetic retinopathy
02:14:09especially because diabetes
02:14:13unfortunately really continues to grow
02:14:15in especially let's say in the United
02:14:18States certainly in the developed world
02:14:23um especially type 2 diabetes with
02:14:25eating habits exercise habits
02:14:28contributing to a proliferation of some
02:14:30of the risk factors for type 2 diabetes
02:14:33metabolic syndrome obesity
02:14:36we're unfortunately seeing a
02:14:38proliferation a growth in the number of
02:14:40people with diabetes and with the growth
02:14:43in diabetes unfortunately comes the
02:14:45growth of the complications of diabetes
02:14:48and one of the major complications of
02:14:51diabetes is damage to the retina inside
02:14:53the eye and we call that diabetic
02:14:55retinopathy and there again some of the
02:14:59damage that occurs
02:15:01especially when in diabetes again some
02:15:04new blood vessels are growing or blood
02:15:06vessels are leaky some of that can be
02:15:08treated with it used to be lasers and
02:15:11now more commonly is often being treated
02:15:13with some of the same injectable drugs
02:15:16that are treating macular degeneration
02:15:19um but there's still a lot of vision
02:15:21loss with diabetes and diabetic
02:15:23retinopathy I think that's an area where
02:15:26again early screening making sure if you
02:15:30have diabetes that's that's an
02:15:32indication where you definitely have to
02:15:33be going in and getting your at least
02:15:36annual exam with an eye care provider or
02:15:39having someone take a photograph of the
02:15:41inside of your eye and rate that
02:15:43photograph to say if you have any
02:15:44diabetic retinopathy or not
02:15:46in terms of interventions can we talk
02:15:49about diabetic retinopathy first because
02:15:51of course type 1 diabetes is a failure
02:15:53to produce insulin relatively rare
02:15:56compared to type 2 diabetes which as you
02:15:58mentioned is proliferating in developing
02:16:01countries right this is probably
02:16:03unprecedented in the sense that
02:16:06developing countries have better Medical
02:16:08Care typically than non-developed
02:16:11more opportunities for food nourishment
02:16:14and yet it's clearly a problem of
02:16:17overnourishment insulin insensitivity
02:16:21is this type of diabetic retinopathy
02:16:24that one observes the same for type 1
02:16:28diabetics versus type 2 diabetics
02:16:30because my understanding is that type 2
02:16:31diabetes this insulin insensitivity is
02:16:36a bit of a Continuum right I mean the
02:16:38type 1 diabetes is as far as I know is
02:16:41all or none you either make insulin or
02:16:42you don't but type 2 diabetes someone
02:16:44could be mildly in insulin insensitive
02:16:47or severely insulin insensitive and
02:16:50sometimes I'm told people are not
02:16:52necessarily obese and can have type 2
02:16:55diabetes as well certainly things like
02:16:57smoking and alcohol intake can
02:16:59contribute to that so how equivalent are
02:17:02type 1 and type 2 diabetes when framed
02:17:05Under the Umbrella of diabetic
02:17:07retinopathy yeah the the time to
02:17:10presentation can be different
02:17:13a type 1 diabetic usually presents with
02:17:18cataclysmic sudden loss sudden sort of
02:17:22final loss of their ability to make
02:17:23insulin it usually presents in childhood
02:17:26or teenage years but can present you can
02:17:29have late onset type 1 diabetes because
02:17:32it's kind of a sudden presentation it
02:17:35can take some years after that to show
02:17:39any diabetic retinopathy whereas just
02:17:41because just just like you said type 2
02:17:44diabetes can be on a Continuum and
02:17:46people can have like kind of a mild type
02:17:482 diabetes but kind of be you know
02:17:50getting along you know going through
02:17:52life kind of maybe not even realizing
02:17:54you know at first and so when you're
02:17:56diagnosed with type 2 diabetes you've
02:17:59probably had some insulin resistance for
02:18:02the years prior to your diagnosis and so
02:18:05in that case you often can have
02:18:08um you know like you're you're at higher
02:18:09risk for presenting sooner with the
02:18:12complications of diabetes like diabetic
02:18:15retinopathy now given that the actual
02:18:21is very similar maybe the same uh
02:18:23between type 1 diabetes and type 2
02:18:25diabetes and again it involves things
02:18:28like leaky blood vessels new blood
02:18:31vessel growth there's some amount of
02:18:33neurodegenerative dysfunction that just
02:18:35simply occurs uh so so uh you can have
02:18:38little little hemorrhages or bleeding
02:18:40spots in the retina tiny little strokes
02:18:43or microvascular uh events in the retina
02:18:46so that can happen in either type 1 or
02:18:49type 2 diabetes once you start having
02:18:51the retinopathy it does look pretty
02:18:54so what can people do to prevent or
02:18:58treat diabetic retinopathy obviously the
02:19:00type 1 diabetic needs to take insulin in
02:19:03order to survive really type 2 diabetics
02:19:05need to get their obesity under control
02:19:07if they are in fact obese and get their
02:19:10blood sugar levels under control
02:19:12regardless that's my understanding and
02:19:16by extension are you seeing any
02:19:19reductions in diabetic retinopathy with
02:19:22people that are taking these glucose
02:19:24like peptide mimics like ozempic which
02:19:27is used to treat type 2 diabetes yeah
02:19:29it's been a very exciting development
02:19:31for the diabetes field this new class of
02:19:37anti-diabetic drugs and
02:19:40um so uh there you've touched on a
02:19:43couple of them there are a few key
02:19:45things for reducing the risk of diabetes
02:19:48or the impact of an diabetes on your
02:19:51retina at risk of diabetic retinopathy
02:19:54or impact of diabetes on your retina
02:19:57uh one is as I mentioned get regular eye
02:20:00exams be screened you know any diabetic
02:20:02should be screened at least once a year
02:20:04uh with a with a good comprehensive
02:20:07retinal exam looking for any of these uh
02:20:10items the number one most important
02:20:14element to prevent diabetic retinopathy
02:20:17is to control your diabetes and having a
02:20:20real good blood sugar control keeping
02:20:22your hemoglobin A1c which is one of the
02:20:25blood tests that gets used to measure
02:20:26how your kind of long-term diabetes
02:20:28management is going
02:20:30uh that's really uh you know first and
02:20:34foremost the most important and that's
02:20:36been shown in large clinical trials they
02:20:38actually randomize patients to hey take
02:20:41care of your diabetes or do a real good
02:20:43job taking care of your diabetes and the
02:20:46patients who did a real good job taking
02:20:48care of their diabetes have much less
02:20:50diabetic retinopathy so that's number
02:20:52one it turns out that if you have high
02:20:56blood pressure and diabetes that blood
02:20:59pressure is also really damaging to your
02:21:03retina also by the way the kidneys and
02:21:05probably all the other organs that are
02:21:07suffering from the diabetic insult so in
02:21:10addition to controlling blood sugar
02:21:11really important to have blood pressure
02:21:14under great control now both blood sugar
02:21:17and blood pressure in type 2 diabetics
02:21:19especially if you're catching them early
02:21:21can be improved with some of these you
02:21:25know so-called Lifestyle Changes like
02:21:27improving eating watching what your food
02:21:29intake is you know getting good exercise
02:21:32trying to lose weight uh so these are
02:21:36definitely on that list of how do you
02:21:39get to good blood sugar and blood
02:21:42but suffice it to say blood sugar and
02:21:46blood pressure control right at the top
02:21:48and then also including the regular at
02:21:52least annual exams and then if diabetic
02:21:54retinopathy is detected and blood sugar
02:21:57and blood pressure control are not going
02:21:58to be enough for that patient we do have
02:22:01treatments as I mentioned before there
02:22:03are drugs that can be injected if your
02:22:04retina is getting you know kind of leaky
02:22:07blood vessels from diabetes there are
02:22:10treatments that we can give the eye
02:22:12specifically to try to counter the
02:22:15diabetic retinopathy terrific in terms
02:22:18of glaucoma as you mentioned glaucoma is
02:22:21related to pressure although there is
02:22:24pressure normal glaucoma
02:22:27glaucoma is a death of the retinal
02:22:30ganglion cells the neurons that connect
02:22:31the eye to the brain and once they are
02:22:34gone at least at this point in human
02:22:35history they can't be replaced although
02:22:38hopefully because of work that you've
02:22:40done in the other Laboratories are doing
02:22:41at some point that statement I just made
02:22:43will not be true in the rgcs can be
02:22:47meanwhile what can and should people do
02:22:51to find out if they have glaucoma
02:22:54and to treat glaucoma
02:22:57and is it true that even if somebody has
02:22:59normal pressure that lowering their eye
02:23:02pressure further protects them against
02:23:04glaucoma yeah that's absolutely right so
02:23:06most important is to get screened with a
02:23:09formal exam at your optometrist or
02:23:12ophthalmologist because you you won't
02:23:14notice you won't have any symptoms if
02:23:17your eye pressure is too high you won't
02:23:19know you're not likely to notice until
02:23:21very late in the disease if your
02:23:24peripheral vision is being damaged
02:23:26through the course of glaucoma so most
02:23:28important us have a screening exam a
02:23:30good comprehensive screening exam will
02:23:32always include checking the eye
02:23:34pressures and also looking in the back
02:23:37of your eye the head of the optic nerve
02:23:40where all the fibers leave the eye and
02:23:42carry the optic nerve information back
02:23:44to the brain we can see that when we
02:23:46look inside your eye and uh and and
02:23:48glaucoma has a fairly characteristic
02:23:51look to it in the optic nerve head so so
02:23:54looking at the optic nerve had uh we
02:23:57have Imaging and peripheral vision
02:23:59testing that can also be included in
02:24:01those screening exams so if you really
02:24:04get a comprehensive screening exam you
02:24:06can very reliably detect if you have
02:24:08glaucoma to worry about or you're in the
02:24:12if you have glaucoma to worry about we
02:24:14have treatments and you're absolutely
02:24:15right whether you start with a
02:24:17abnormally high pressure or you start
02:24:19with a pressure that's on the face of it
02:24:22in the normal range
02:24:24in either case lowering the pressure has
02:24:26been shown in large properly controlled
02:24:29clinical trials to slow the progression
02:24:33of optic nerve damage and vision loss so
02:24:37absolutely in either case starting with
02:24:40high pressure or starting with normal
02:24:41pressure in either case you've got to
02:24:43lower the pressure further and as I
02:24:45mentioned we have eye drops those are
02:24:47usually the first line there's very good
02:24:49data that there's a very benign
02:24:52non-invasive laser it's not the same
02:24:54kind of laser that gets used for Lasik
02:24:55but there's a benign very safe type of
02:24:58laser called selective laser
02:25:01trabeculoplasty SLT we call it and
02:25:04that's also very effective as a first
02:25:06line actually in the largest clinical
02:25:08trial from which the data have been
02:25:11coming out just even over the last few
02:25:12years it's called the light trial in the
02:25:15light trial patients with glaucoma were
02:25:17randomly assigned to either get the
02:25:19laser or the sort of most common first
02:25:22strongest eye drop and uh that gets used
02:25:26clinically and actually
02:25:29on many features they both worked at
02:25:31least as well but when looking out over
02:25:34the long term actually the laser had
02:25:35some advantages over the eye drop not in
02:25:38the least of which by the way it's very
02:25:39nice for patients to not have to like
02:25:41remember to use the eye drop every night
02:25:43and so um so that's quite helpful I
02:25:45think uh to to keep in mind as a
02:25:48treatment option uh early in the course
02:25:50of the disease of course if the eye
02:25:52drops under our lasers are not enough
02:25:55early in the disease we also have
02:25:56surgical approaches to lower the eye
02:25:58pressure further you know even with all
02:26:01of our treatments all of these
02:26:04treatments stepping patients through all
02:26:07about 10 15 even 20 percent of patients
02:26:11will lose very meaningful functional
02:26:13vision and maybe five ten fifteen
02:26:15percent of patients especially depending
02:26:17where you are in the world will go blind
02:26:21including in you know quote-unquote
02:26:25developed countries uh there's still a
02:26:28very significant cohort of patients that
02:26:31go blind legally blind and then you know
02:26:34absolute blindness I can't even tell if
02:26:36the lights are on in the room uh so it's
02:26:39it's it's it's devastating it's
02:26:41Insidious it's hard to detect early
02:26:45um and so glaucoma's still a tough one
02:26:47even with all of the treatments that we
02:26:49have okay so get your pressures checked
02:26:52folks and if you are prescribed drops
02:26:57I hear about patients not taking their
02:26:58drops which to me just seems like
02:27:01baffling but I guess having to do
02:27:04something day in and day out is it can
02:27:06be Troublesome enough that unless people
02:27:08are losing their Vision very quickly or
02:27:10they are very afraid of losing their
02:27:11Vision sometimes they just neglect to
02:27:13take them it's hard it's hard for
02:27:15glaucoma eye drops it's hard for taking
02:27:17your blood pressure medication it's hard
02:27:19for a lot of medicines you know if
02:27:20you're if you're taking a medicine where
02:27:22you don't feel better you know if you
02:27:23have a headache and you take an aspirin
02:27:26or Tylenol or an ibuprofen uh you know
02:27:29you feel better you feel reinforced gosh
02:27:31taking that pill made sense right but if
02:27:34you're using an eye drop that like hey
02:27:36this is going to protect you for the
02:27:37next 20 years from losing your vision
02:27:39but you don't notice every day that
02:27:42anything's better and by the way the eye
02:27:44drops could be a little irritating maybe
02:27:46it stings a little for a minute or two
02:27:47and you put it in your eye some people
02:27:49are even less tolerant of the eye drops
02:27:51it's hard to feel motivated every day
02:27:53and we know that we call that compliance
02:27:55we know that it's very hard for patients
02:27:57to stay compliant with prescribed
02:28:00medications where they don't feel or
02:28:03notice a difference in a daily way
02:28:07I realize that we can't stop aging
02:28:11um but right now you can't stop aging
02:28:13and age is a risk factor for glaucoma my
02:28:16understanding is so is smoking or vaping
02:28:22and so is alcohol
02:28:25and by that reasoning should people
02:28:28strive to drink less and smoke less
02:28:30including vaping nicotine less if they
02:28:33are concerned about glaucoma yeah and
02:28:36not just glaucoma macular degeneration
02:28:37actually macular degeneration has a
02:28:40couple major risk factors macular
02:28:42degeneration aging just like with
02:28:44glaucoma major risk factor
02:28:47smoking including exposure to secondhand
02:28:50smoke major risk factor for macular
02:28:52degeneration and for the progression and
02:28:54vision loss potentially associated with
02:28:56macular degeneration in the case of
02:28:58macular degeneration there's also a
02:29:00couple of genes that we've sequenced the
02:29:02human genome and there's a couple of
02:29:03genes associated with magnet generation
02:29:06that's less true for your typical
02:29:08run-of-the-mill adult Kuma there are
02:29:10genes for the Pediatric and infantile
02:29:12forms of glaucoma uh so yeah smoking a
02:29:16hundred percent including vaping uh it's
02:29:19a No-No for your eyes just like it's a
02:29:21No-No for the rest of your body and uh
02:29:23it's tough as the eye doctor to have
02:29:25these conversations with patients
02:29:27because you kind of feel like well you
02:29:29know they must know it already and I'm
02:29:32trying to be the good guy in the room
02:29:33with the patient convince them to use
02:29:35their other medications but it's it's
02:29:37important for us also as Eye Care
02:29:39Providers to reinforce the message with
02:29:42our patients a smoking terrible idea uh
02:29:46for maca degeneration also for glaucoma
02:29:49you know glaucoma is interesting because
02:29:51the optic nerve where it degenerates
02:29:52kind of right at the head of the optic
02:29:54nerve where it exits the eye it's what
02:29:57we call a watershed Zone it's kind of an
02:29:59edge of two blood vessel supplies and if
02:30:03either of those blood vessels supplies
02:30:05are a little bit short on blood or
02:30:07oxygen supply to that optic nerve head
02:30:09your glaucoma is going to get worse your
02:30:12optic nerve is going to be under fed and
02:30:14that's going to worsen this degenerative
02:30:15process just by not having all the right
02:30:17nutrients and oxygen so the other thing
02:30:20is that especially for glaucoma
02:30:22everything that we talk about for being
02:30:27for the rest of our body is is almost
02:30:30certainly true for glaucoma and so I
02:30:32also always counsel glaucoma patients
02:30:34it's not just no smoking but eat healthy
02:30:37have a multivitamin uh get some exercise
02:30:40all those things that are good for your
02:30:42cardiovascular system are going to be
02:30:44good for your eyes in general and in
02:30:46particular if you have glaucoma or at
02:30:50risk high risk for glaucoma I realize
02:30:53that smoking or vaping are problematic
02:30:55for glaucoma and for macular
02:30:57degeneration but we can't have a
02:30:59conversation about glaucoma without at
02:31:01least mentioning cannabis I did an
02:31:03entire episode about cannabis which
02:31:05touched on some of the real dangers of
02:31:07very high THC concentration cannabis
02:31:09this lost me a few
02:31:11um followers I'm sure no problem because
02:31:14what was important was to convey the
02:31:16fact that the Cannabis that's out there
02:31:19nowadays comes in a variety of different
02:31:21strains and ratios of THC to CBD there's
02:31:25some severe risks of high THC especially
02:31:28in young males although not always the
02:31:31point being that there are and I want to
02:31:33be very clear about this because for
02:31:35whatever reason cannabis gets people
02:31:36really up in arms they always say it's
02:31:37not as bad as alcohol but guess what we
02:31:39did an entire episode about alcohol and
02:31:40there the message is very clear zero is
02:31:42better than any and two a week is
02:31:44probably the limit and if you're an
02:31:45alcoholic zero is the rule so
02:31:49with cannabis it's clear by my read of
02:31:53the data that it can lower eye pressure
02:31:55which may undermine the progression of
02:31:58glaucoma somewhat but if people are
02:32:00smoking that cannabis is it therefore
02:32:02going to offset any gain that one would
02:32:04get from that cannabis and then how does
02:32:07one account for the potentially
02:32:09problematic aspects of very high THC
02:32:11cannabis yeah it's a great question and
02:32:14the truth is is that in most patients
02:32:16cannabis will lower the eye pressure the
02:32:20problem is is it really only lowers that
02:32:22eye pressure During the period that
02:32:24you're high from the Cannabis and the
02:32:27second problem is that smoking version
02:32:30of getting that cannabis into your
02:32:32system the smoking is bad for your lungs
02:32:34by the way the smoke from Cannabis or
02:32:37from cigarettes is also terrible for
02:32:40your dry eyes it causes inflammation it
02:32:43dries out your eyes so it's also very
02:32:46bad from that perspective now so the the
02:32:49problem with cannabis is not that it
02:32:51doesn't work to lower the price we want
02:32:52to lower the pressure that's great the
02:32:54problem with cannabis is that it's not
02:32:56realistic for most of our patients
02:32:59to prescribe could you go out and be
02:33:02high from Cannabis 24 hours a day seven
02:33:05days a week for the next 20 years I'm
02:33:07sure some people have tried and
02:33:10um but right that's not practical for
02:33:12most people and certainly for young
02:33:13people it could be really especially
02:33:15problematic yeah I should say absolutely
02:33:17so so I recommend not taking that
02:33:19approach but that said I I'm definitely
02:33:22not a decryer of it and now that there
02:33:24are edible forms I certainly have
02:33:26patients who are using it in a
02:33:29responsible way uh especially edible
02:33:32forms and uh and in select cases like
02:33:35that could make the difference for them
02:33:37helping to keep the pressure down and
02:33:38I'll say for example you know it turns
02:33:40out you've talked a lot over the last
02:33:43couple years about diurnal curves and
02:33:45circadian rhythms it turns out that our
02:33:48eye pressure also undergoes a circadian
02:33:51rhythm and it's actually highest at
02:33:53night while we're sleeping kind of peaks
02:33:55in those early morning hours then hits a
02:33:57low throughout the early day and then
02:33:59kind of rises again throughout the
02:34:01afternoon into the evening and we have a
02:34:03lot of patients who they come into their
02:34:05Clinic visit their eye pressure looks
02:34:06normal but it's actually quite a bit
02:34:08higher when they're at home and that
02:34:10could explain some fraction of what we
02:34:12call normal pressure glaucoma it just
02:34:14looks normal during the day it's
02:34:15actually high at night and so in
02:34:18particular some patients I certainly
02:34:19have some patients who are using these
02:34:21products like let's say before bed and
02:34:24if it's controlling their eye pressure
02:34:26at night while they're asleep when the
02:34:28eye pressure would have been the highest
02:34:29it may confer some protective advantage
02:34:32over time but that said again like for
02:34:35most patients it's not going to be the
02:34:36primary approach I'm most excited about
02:34:40you know Laboratories or companies
02:34:43figuring out which
02:34:45the compounds Within These cannabinoids
02:34:49they're called within these products are
02:34:52actually responsible for lowering the
02:34:54eye pressure and could we get like a
02:34:56more potent eye specific
02:34:59long-acting drug that's basically
02:35:02derived from the concept of cannabis but
02:35:05works better and is more compatible with
02:35:08not bringing along all the other adverse
02:35:10elements that can come with cannabis use
02:35:13you mentioned the Circadian rhythm and
02:35:15eye pressure and the fact that eye
02:35:18pressure is higher at night
02:35:19is there any advantage to sleeping in a
02:35:23particular position I know this might
02:35:24sound a little detailed but I seem to
02:35:26recall an abstract or a paper a few
02:35:27years ago at a meeting that you and I
02:35:29both attended were that said that if
02:35:31people slept with their head below their
02:35:33feet eye pressures were higher than if
02:35:35their head was slightly elevated above
02:35:36their feet and for somebody who has
02:35:38glaucoma this could make a pretty
02:35:40substantial difference in terms of their
02:35:41eye pressures at precisely the hours of
02:35:43the night we should say in which they
02:35:46could be doing the most damage to the
02:35:48ganglion cells yeah absolutely and we
02:35:51will sometimes counsel patients with
02:35:53severe glaucoma especially if they're
02:35:55you know poorly responsive to standard
02:35:57therapies or poorly able to tolerate
02:36:00standard therapies we'll counsel them if
02:36:03they're able to sleep up on a couple
02:36:04pillows get kind of a 30 degree sleep
02:36:07angle going what I don't want to do is
02:36:10interfere with a person's sleep because
02:36:12I just I fundamentally feel for the
02:36:14total health of the whole human being
02:36:17getting a good night's sleep is maybe
02:36:20more important than that 30 degrees and
02:36:22if trying to sleep up on pillows at 30
02:36:24degrees it's going to lead to kind of
02:36:25restless difficult sleep night I'd
02:36:28rather the patient get a good night's
02:36:30sleep but if they can tolerate it and
02:36:32especially if they have a sort of a
02:36:34tough version of glaucoma then we'll
02:36:37we'll let them try see if they can sleep
02:36:39up the other really interesting question
02:36:41that arises is uh does which side you
02:36:45sleep on affect uh which I might have
02:36:48worse glaucoma glaucoma is almost always
02:36:50with with a few rare exceptions almost
02:36:53always a disease of two eyes but it can
02:36:55present very asymmetrically in fact it's
02:36:58quite common to have one eye kind of
02:37:00have worse damage than the other and and
02:37:02we don't know fundamentally why that is
02:37:04but one hypothesis was gosh maybe if you
02:37:07sleep on the right eye uh then your
02:37:09right eye will have worse glaucoma
02:37:11because the pressure is a little higher
02:37:12down below or maybe it's pressing on the
02:37:15pillow in a way or some something like
02:37:18that there have been a couple studies
02:37:19really really looking at that question a
02:37:22couple Studies have said the lower aisle
02:37:24have worse glaucoma a couple Studies
02:37:26have said the higher I will have worse
02:37:28glaucoma so the upshot is it probably
02:37:30doesn't matter which side you sleep on
02:37:32we also know when you video people in
02:37:34their normal sleep pattern even if you
02:37:36feel you always fall asleep on the left
02:37:39side of your face people toss and turn
02:37:41all night probably over the course of
02:37:43the night you're spending a similar
02:37:44amount of time on each eye I'm glad you
02:37:47brought up that point in terms of
02:37:49macular degeneration I'm curious about
02:37:51the things that people can do as opposed
02:37:54to the don'ts in order to perhaps offset
02:37:57macular degeneration one of the things
02:37:58that I'm intrigued by are the results of
02:38:00Glenn Jeffery's laboratory over at
02:38:02University College London I had known
02:38:03Jeff for probably a decade or more and
02:38:06he typically worked on animal models but
02:38:09then a few years ago started publishing
02:38:11studies I believe there are now two
02:38:12published studies showing how red light
02:38:16and near infrared
02:38:18light exposure done early in the day to
02:38:21the eye at a distance of about two feet
02:38:23for just a couple of minutes a few times
02:38:25a week could offset some of the vision
02:38:28loss associated with age-related macular
02:38:30degeneration in people older than 40.
02:38:33that's my understanding of these studies
02:38:34and there's a theory there about
02:38:35enhancing function of mitochondria and
02:38:37photoreceptors by reducing reactive
02:38:39oxygen species there's a whole
02:38:40mechanistic hypothesis but
02:38:43my question is is that the sort of
02:38:46protocol that produces significant
02:38:48enough offset of macular degeneration
02:38:51like we should all be looking at red
02:38:52lights in the morning
02:38:54um or is it still too early days in
02:38:57order to really conclude that
02:39:00data is very compelling the data are
02:39:03very compelling that this kind of red or
02:39:06near infrared light therapy can be at
02:39:09some level neuroprotective and yes uh
02:39:11the the data suggests that uh kind of
02:39:15ramping up high high functioning
02:39:18mitochondria is a part of that
02:39:20activating neuroprotective Pathways in
02:39:22the retina it's actually been
02:39:24demonstrated in animal models and a
02:39:27little human data here and there but
02:39:28both for macular degeneration kind of uh
02:39:31degenerative is but also for optic
02:39:34neuropathies you know like glaucoma
02:39:36retinal ganglion cells the cells that
02:39:38carry all that visual information from
02:39:40the eye to the brain they're chock full
02:39:42of mitochondria too and uh and so the
02:39:45idea that this could be a therapeutic
02:39:47approach I think is very compelling
02:39:49there are a number of studies actually I
02:39:51think still ongoing today
02:39:53really trying to figure out what's the
02:39:55right dose how much brightness do you
02:39:57need is there an optimal wavelength how
02:40:00many minutes does it matter when during
02:40:02the day you provide that light or how
02:40:05many minutes or hours
02:40:07um these are still very much open
02:40:10questions you know what's the dose
02:40:11what's the delivery
02:40:13um but it's it's it's it's it's very
02:40:16promising looking and there's biological
02:40:18premise and I'm excited to see where
02:40:20that goes because again that's like a
02:40:22that's a very accessible uh sort of
02:40:25therapeutic approach that could be
02:40:27brought to a very broad swath of of
02:40:30people so I'm excited about that sorry I
02:40:33didn't mean to interrupt and completely
02:40:36um I should um probably mention a
02:40:39warning which is if people are going to
02:40:40decide that they're going to jump on
02:40:42this result and do red light exposure in
02:40:44the early part of the day no matter what
02:40:46color a light is if it's too bright you
02:40:48can damage your eye so I think this is
02:40:51why you're pointing the fact that we
02:40:52need established protocol calls before
02:40:55people really start blasting their eyes
02:40:57with red light and if they are going to
02:40:58expose themselves to Red Light it
02:41:00shouldn't be uncomfortably bright do I
02:41:01have that yeah that's absolutely right
02:41:03you know actually uh light effect
02:41:06um we talked about this a little bit
02:41:08um there's actually now data also that
02:41:11red light and actually interestingly
02:41:13studies using light at the other end of
02:41:16the visible spectrum violet light either
02:41:18of those in small daily doses can also
02:41:22be used to prevent progression of
02:41:25nearsightedness in children in
02:41:27school-aged children and so I think
02:41:29we're really just on the cusp of really
02:41:31understanding the biology of how these
02:41:34different light therapies might be
02:41:36leveraged maximally to to maximize our
02:41:40Eye Health and both during development
02:41:42and at the other end of the spectrum as
02:41:45we age so it's an exciting area and I
02:41:48think this kind of phototherapy is uh
02:41:50you know a very hot topic for research
02:41:53right now very hot topic one has to
02:41:56wonder whether or not these light
02:41:57therapies the fact that infrared works
02:41:59and maybe ultraviolet works is are
02:42:02really just capturing some of what
02:42:05is naturally doing when as you mentioned
02:42:08before a child or perhaps an adult also
02:42:10spends a certain number of hours
02:42:11outdoors I mean maybe we're just filling
02:42:13in the blanks that are neglected
02:42:15nowadays because we're spending so much
02:42:16time indoors under artificial lights and
02:42:18in front of screens yeah yeah
02:42:20very thoughtful possibility yeah
02:42:23I have a couple of we don't have to call
02:42:25them quick questions but common
02:42:27questions that perhaps have a brief uh
02:42:31explanations uh for instance I put out a
02:42:34request for questions in an anticipation
02:42:36of this episode and I got a lot of
02:42:38people asking what are floaters in the
02:42:41eye and is there anything that people
02:42:43can do to get rid of floaters yeah our
02:42:46eye when we're born is actually filled
02:42:48in the middle of it with a jelly it's
02:42:50not just fluid it's kind of a jelly
02:42:52there's collagen fibers and thankfully
02:42:54the whole jelly is largely invisible so
02:42:58the light can get through our eye back
02:42:59to the retina without being impeded as
02:43:03we age those different fibers and gels
02:43:06shrink and contract and they peel off of
02:43:11the back of the retina so there's just
02:43:13in the middle now your your eyeball
02:43:14doesn't shrink because it fills in with
02:43:17with fluid with salt water basically but
02:43:19the gel part shrinks and as it shrinks
02:43:22and also pulls peels off the retina it
02:43:26can pull off kind of little tiny retinal
02:43:28bits not important to your vision bits
02:43:31but just like little tissue bits and
02:43:33also as it congeals it kind of uh can
02:43:35get little concretions in the jelly and
02:43:38we perceive those as floaters you know
02:43:41little almost semi-translucent or in
02:43:43some cases kind of grayish blackish
02:43:46sometimes sometimes you get a big one if
02:43:48it peels off the edge of the optic nerve
02:43:50in the back of the eye as happens we
02:43:52call that a posterior vitreous
02:43:53detachment you can actually see like a
02:43:55moon or a half moon floater in Your
02:43:58Vision these are very frustrating to a
02:44:04um and uh the good news is in almost all
02:44:07cases they will just go away by
02:44:09themselves in theory it's been played
02:44:12with gosh we could do like a big surgery
02:44:14to chew up all that jelly replace it all
02:44:17with salt water try to get rid of your
02:44:19floaters there's risk associated with
02:44:22that surgery we use it very effective
02:44:23actively in a retinal detachments or
02:44:26other diseases bad diabetic retinopathy
02:44:28bleeding inside the eye we can take out
02:44:31the jelly from the eye replace it with
02:44:32with salt water but that's not
02:44:36um you know putting patients through the
02:44:38risk of that surgery just to get rid of
02:44:40a couple of floaters or a few floaters
02:44:42that probably are going to go away over
02:44:45the next few months I actually like to
02:44:48tell patients it's nothing to worry
02:44:50about just ignore them and actually if
02:44:53you stop focusing on them your brain
02:44:55will actually start filtering them out
02:44:57you'll stop noticing them if you can
02:45:00kind of uh not worry about them be a
02:45:03little intentional about ignoring them
02:45:05in the beginning and then they do
02:45:06actually go away and look some will go
02:45:08away these three will go away these two
02:45:10will appear eventually you'll stop
02:45:13having floaters most patients will stop
02:45:15having floaters so we really don't like
02:45:19to put a patient at risk by intervening
02:45:21we really like to in this case just
02:45:23reassure them it's going to be okay just
02:45:25ignore them they'll eventually go away
02:45:27thank you for that answer
02:45:30twitching of the eye is something that
02:45:33people complain about I know when I get
02:45:34tired I'll get a twitch over one eye I
02:45:37think there's a condition is it called
02:45:39myasthena gravis where people go through
02:45:41a stressful period or get very fatigued
02:45:43and I think that's a depletion of the
02:45:45nerve terminal communication between the
02:45:48nerves that control the muscles of the
02:45:50eye and then people get this kind of
02:45:51like hooded eye look
02:45:53um where they have a hard time opening
02:45:55their eyes but barring something extreme
02:45:57like myasthena gravis
02:45:59or staying up for two days working or
02:46:02even just being a bit sleep deprived
02:46:04what causes the twitching of the eyelid
02:46:06and is there anything people can do
02:46:08about that most the time it's actually
02:46:10just a bad nerve ending you know maybe
02:46:12that one nerve cell you know your eyelid
02:46:15is fed by you know hundreds maybe it's
02:46:19thousands of nerve cells that are doing
02:46:21the muscles they're doing the feeling
02:46:22obviously if the ones controlling the
02:46:24muscles that can lead to a twitch if one
02:46:27of those nerve cells kind of just starts
02:46:29you know maybe that one nerve cell is
02:46:31dying just you know whatever the age you
02:46:33can process uh you know it happens in
02:46:36young people too though so you got one
02:46:38bad fiber that's just deciding to kind
02:46:41of ring off the hook that's that's that
02:46:43telephone's just ringing off the hook
02:46:45and it's just activating the muscle so
02:46:47you're just twitching that muscle I've
02:46:50had them as well and you can have
02:46:51notches in your eyelids you can have
02:46:53this anywhere in your body like one
02:46:55little spot on your leg where just the
02:46:57muscle right under the skin again is
02:47:01and typically it'll happen over the
02:47:04course of a couple of months
02:47:06intermittently some days more sometimes
02:47:09less maybe it correlates with when
02:47:10you're tired a little bit sometimes and
02:47:13then it'll stop that nerve cell will
02:47:15either reconnect properly and stop doing
02:47:17that maybe it dies we don't really know
02:47:19but typically it lasts on that scale now
02:47:22there are other diseases not just
02:47:24myasthenia gravis you can have blepharos
02:47:27spasm like where you have a chronic
02:47:28spasming of of certain nerves causing
02:47:33muscles to spasm and there we we can use
02:47:36we can use treatments for example Botox
02:47:38as a treatment that you know people use
02:47:41for cosmetic reducing of wrinkles for
02:47:44example but you know a really good
02:47:46medical use of Botox is preventing that
02:47:48blepharospasm and patients can come in
02:47:50once every three or six months if they
02:47:52have a really severe spasming version of
02:47:55what you're describing but the regular
02:47:57occasional run-of-the-mill lasts a
02:47:59couple months nothing to worry about it
02:48:02does not pre-sage anything bad happening
02:48:04in your future and maybe let it run its
02:48:07course and you'll be okay great
02:48:11we've all heard that carrots are good
02:48:13for our vision which presumably stems
02:48:16from some peripheral understanding about
02:48:18the fact that vitamin A is integral to
02:48:21the photosynthesis pathway of converting
02:48:23light into electrical and chemical
02:48:25signals that the rest of the eye brain
02:48:27can use and yet I'm guessing that there
02:48:29probably aren't that many people walking
02:48:31around who are vitamin A deficient
02:48:33they're probably out there but not that
02:48:34many especially in developed countries
02:48:37and in addition in the last really five
02:48:40years but in particular in the last two
02:48:43years I've seen a proliferation of
02:48:45supplements on the market to promote Eye
02:48:47Health and Longevity of vision
02:48:50I'd love your thought on this General
02:48:53theme of nutrition and supplements for
02:48:57improving Eye Health or for maintaining
02:48:59Eye Health and before we started
02:49:01recording you mentioned that
02:49:03Ophthalmology or at least Eye Health is
02:49:05one area of medicine that has a bit not
02:49:08extensive but a bit of a longer history
02:49:11of exploring supplementation in rigorous
02:49:14randomized control trials whereas other
02:49:17areas of Neuroscience and Neural Health
02:49:19such as Alzheimer's Etc certainly there
02:49:22are brain health supplements out there
02:49:24but there aren't a lot of rigorous data
02:49:26to support them just yet so what are
02:49:27your thoughts on nutrition
02:49:29um aside from the standard thing of you
02:49:31know people shouldn't be ingesting too
02:49:33many calories such that they are obese
02:49:35and diabetic and therefore you know Etc
02:49:36indirect effects of nutrition
02:49:39um what are your thoughts on nutrition
02:49:41and supplementation for Eye Health yeah
02:49:44you know you're absolutely right and
02:49:46again in Ophthalmology we actually do
02:49:48have quite a bit of studies there's been
02:49:49quite a bit of attention over the years
02:49:51even over the decades looking at this
02:49:53question and I think it's worth
02:49:56um a couple of yeses and a couple of
02:49:59for macular degeneration which we talked
02:50:01about being an exceedingly common cause
02:50:04of vision loss there have been two
02:50:07age-related eye disease studies called
02:50:11arids age-related eye disease studies
02:50:13era there is arids and then arids too
02:50:15and those studies were a large
02:50:18randomized Trials of using giving giving
02:50:22patients supplements and in arids it was
02:50:28uh higher dose than would just come in a
02:50:34and then also beta-carotene
02:50:37and beta-carotene is one of these what
02:50:39are called carotenoids it's a it's a if
02:50:41you look at the extended family there's
02:50:42maybe 600 different chemical entities of
02:50:46these carotenoids and beta-carotene is
02:50:48one of them that's in the direct pathway
02:50:50of making vitamin A and so that was the
02:50:52principle in the Arid study and the Arid
02:50:55studies showed that patients randomized
02:50:57to these pills compared to controls it
02:51:00it did these are antioxidants in part
02:51:03right in addition to feeding into that
02:51:05vitamin A pathway and um and the
02:51:08patients randomized to get that
02:51:09supplement mixture
02:51:11showed less progression of their dry
02:51:15macular degeneration in the moderate to
02:51:18severe ranges if you had mild macular
02:51:20degeneration they didn't show a
02:51:22statistically significant Improvement
02:51:24but I will say it's my experience you
02:51:26know myself with patients and and seeing
02:51:28how the field works you know if you have
02:51:30mild macular degeneration even though
02:51:32it's not as clinically proven we're
02:51:34still often recommending hey if you can
02:51:36afford that supplement go ahead and buy
02:51:38that now arids Was Then followed by a
02:51:41second study arids too also with vitamin
02:51:43C vitamin E zinc and copper they
02:51:47actually tested whether a slightly lower
02:51:49dose of zinc would be as good as a
02:51:51higher dose and a lower dose was as good
02:51:52as a higher dose and then instead of the
02:51:55beta-carotene they tested against the
02:51:57beta-carotene they tried two other
02:52:00carotenoids that are called lutein and
02:52:02zeaxanthine and and they actually found
02:52:05head to head that the second the arids
02:52:09II formula without the beta-carotene and
02:52:11with the lutein and zeaxanthin that that
02:52:14formula was even better at slowing dry
02:52:18macro degeneration in the moderate to
02:52:21severe population again it's not clear
02:52:23how much it may help mild back the
02:52:25generation but in the uh sort of
02:52:28clinically defined moderate towards
02:52:30severe group there was a statistically
02:52:32significant it reduced it by about 20 25
02:52:34the progression of your dry Market
02:52:37generation and you know over a couple of
02:52:40years 25 five percent you may not notice
02:52:42but over a couple of decades you know
02:52:44that could really slow down the
02:52:46progression of your disease
02:52:48now it turns out that the beta carotene
02:52:51they noted a little bit of an increased
02:52:53cancer risk in the patients in the arids
02:52:55one who had that beta-carotene mostly in
02:52:58patients who are smokers
02:53:00they also noticed in the second one that
02:53:02if you were already not taking a
02:53:04multivitamin or not eating a diet that's
02:53:07already naturally rich in lutein or
02:53:10zeaxanthin that the effect of that
02:53:12supplement was even stronger
02:53:15so it was very strong clinical trial
02:53:18support for taking what we now use this
02:53:21arids II supplementation and I'm sure we
02:53:25can list the formula or put it in the
02:53:27links under under your podcast uh uh
02:53:30that that thus really does slow macular
02:53:33degeneration so that's like a very
02:53:35strong example of a yes you should do
02:53:39there's one yes brewing in the glaucoma
02:53:43field right now and that's high dose
02:53:46vitamin B3 B is in boy three it's also
02:53:50called in its various forms either
02:53:52nicotinic acid or nicotinamide uh the
02:53:56nicotin sounds like nicotine but this is
02:53:59not a substitute for smoking or vaping
02:54:01this is a different this is a vitamin
02:54:03that just has a very similar sounding
02:54:05name it's in the NAD synthesis pathway
02:54:07that's exactly right it's in the NAD
02:54:09pathway NAD is one of the oxidative
02:54:12stress regulators and energy Regulators
02:54:15of our cells so it's a very critical
02:54:18molecule in the metabolism of our cells
02:54:20and there was very strong evidence in
02:54:23pre-clinical models of mice given
02:54:25glaucoma that manipulating this pathway
02:54:28and sort of increasing this pathway
02:54:31could be protective in glaucoma or other
02:54:34optic neuropathies optic nerve
02:54:36degenerative diseases and so there have
02:54:39now been been too limited but randomized
02:54:43controlled clinical trials one looking
02:54:46at glaucoma patients looking at their
02:54:48visual field so their actual visual
02:54:49performance and the other looking at the
02:54:52electrical signals in the eye called an
02:54:54electroretnogram kind of like an EEG
02:54:56does for your brain we can do an ERG for
02:54:59your retina and in both of those trials
02:55:02high-dose vitamin B3 was a found to be
02:55:07very safe and B was shown to actually
02:55:10improve at least in the short term
02:55:12improve retinal function measured either
02:55:15on visual field testing or on the
02:55:18electro retinogram now this is now
02:55:23clinical trials large kind of phase 3
02:55:26style clinical trials actually around
02:55:29the world it's a very hot topic for
02:55:31glaucoma the fact that this NAD boosting
02:55:34supplementation with high-dose vitamin
02:55:37B3 might be a great approach to helping
02:55:39protect the nerve in in glaucoma and so
02:55:44as I say there's there's three or four
02:55:46large randomized phase three style
02:55:49clinical trials uh starting now and so
02:55:52over the next year or two we'll get more
02:55:54data but I'll tell you like I have
02:55:57patience and if they're at the end of
02:56:00their rope and we are having a lot of
02:56:02trouble controlling their vision loss
02:56:04from glaucoma I'm already recommending
02:56:06in these limited cases uh hey why don't
02:56:09you try this it's almost certainly safe
02:56:12and it may and it may help and it may
02:56:15help protect your vision over time so so
02:56:18that's that's an area that's kind of
02:56:20another like kind of could be a yes
02:56:22early data's point in the right
02:56:24direction you want to be careful but uh
02:56:27but I but I am starting to recommend it
02:56:30at the same time that we're actually
02:56:31doing the clinical trials now that said
02:56:34there are a lot of other things that
02:56:36people talk about other supplements
02:56:39ginkgo biloba things with generic names
02:56:42on the internet like you know glaucoma
02:56:44preservation you know uh yeah that sort
02:56:47of thing makes my uh gives me hives you
02:56:50know yeah and these are areas where
02:56:52there might be scientific premise like a
02:56:56plausible explanation for how this
02:56:58should help but not good data that it
02:57:01actually helps thankfully in most cases
02:57:04these things are safe uh but I just
02:57:07worry about patience
02:57:08hitching their wagon to something that's
02:57:10not going to help them getting their
02:57:12hopes up uh worst case scenario not
02:57:15taking their actually proven prescribed
02:57:18treatments and instead using an
02:57:20alternative therapy that doesn't have
02:57:22data to support it and so I think there
02:57:24there's a lot of you know
02:57:27um uh you know either unfounded
02:57:30unsupported uh you know information it
02:57:34travels around chat rooms travels around
02:57:36the internet one person tells the next
02:57:38person you know there's inappropriate
02:57:40advertising for some of these uh and
02:57:43they're you know I really don't want
02:57:45patients to be hurt not necessarily hurt
02:57:48by taking something that's not helping
02:57:49but but maybe hurt by feeling like I
02:57:52don't have to go to the doctor I'm
02:57:53taking this supplement and that would be
02:57:55obviously a really bad potential outcome
02:57:57for a patient yeah I completely agree
02:57:59supplements are just as the name
02:58:02suggests a supplement to an already
02:58:06hopefully healthy lifestyle and use of
02:58:09medication where it's prescribed and
02:58:11I've often said on the podcast that
02:58:13sometimes the best dose of a supplement
02:58:15is zero milligrams so I do appreciate
02:58:19you touching on those themes because
02:58:21um supplementation is something that
02:58:22comes up from time to time on the
02:58:24podcast and I know that I've certainly
02:58:26have seen a number of these different I
02:58:28Envision support supplements we aren't
02:58:30affiliated with any of them I don't
02:58:33personally take any of them but these
02:58:36clinical trials sound promising so I'm
02:58:38going to keep an ear to the ground for
02:58:43as a final question and hopefully a
02:58:46topic that we can cover in more detail
02:58:47in a subsequent episode of the podcast
02:58:50because I absolutely want to have you
02:58:51back to discuss this in more detail
02:58:53I'd like to just get your thoughts on
02:58:55the fact that the neural retina is in
02:58:57fact neural and it's part of the brain
02:58:59and we are hearing an increasing amount
02:59:02of positive chatter about the use of
02:59:05Imaging the eye and the retina directly
02:59:08as a way to detect other forms of
02:59:10neurodegeneration for those that are
02:59:12listening or for watching
02:59:14um you know I'm putting my hands up in
02:59:16kind of C shape at the back of your eye
02:59:18is lined with these with this three cell
02:59:21layer thick thing that is the neural
02:59:22retina which are really pieces of brain
02:59:24that connect to the rest of the brain
02:59:26and because it resides in the eyes and
02:59:29outside the cranial Vault people like
02:59:32skilled clinicians with the appropriate
02:59:34tools can look into the eye and see the
02:59:37brain directly without having to cut
02:59:39through the skull
02:59:40and my understanding is that more and
02:59:42more ophthalmologists are seeing
02:59:45cases where degeneration of the retina
02:59:48is correlated with degeneration of
02:59:52structures deeper in the brain making
02:59:54Imaging of the neural retina perhaps one
02:59:56of the best diagnostic tools for
02:59:58predicting and tracking the progression
03:00:00of Alzheimer's and other forms of
03:00:01neurodegeneration do I have that right
03:00:03yeah absolutely actually this is a super
03:00:05exciting area you know we we have this
03:00:07long-standing sang in Ophthalmology that
03:00:09the eye is a window to the brain the
03:00:11eyes of window to the soul of course is
03:00:13a log standing sang right and and it
03:00:15turns out that you know in Alzheimer's
03:00:18disease as an example you know we really
03:00:21talk a lot about the degeneration of
03:00:24basal forebrain cholinergic neurons that
03:00:26are leading to the cognitive deficits in
03:00:29Alzheimer's disease but it turns out
03:00:31that there is also some degeneration
03:00:33throughout other areas of the brain
03:00:35including the retina and since we have
03:00:37such a relatively easy time Imaging the
03:00:40retina you can go into your doctor's
03:00:42office and get a quick little sort of
03:00:44laser scan of the retina a picture of
03:00:46the ratna compared to like going through
03:00:48a full MRI processor for your brain
03:00:51and we can detect the degeneration of
03:00:55the retina and optic nerve associated
03:00:57with Alzheimer's disease it looks like
03:00:59the same thing is happening in
03:01:00Parkinson's disease in Ms now one of the
03:01:03issues is that in a lot of these
03:01:06degenerative diseases were able to
03:01:08detect the difference in the retina but
03:01:10were not necessarily able to say hey if
03:01:13we see this in the retina it's multiple
03:01:15sclerosis but if we see that in the
03:01:17retina it's Alzheimer's disease so there
03:01:20may not be there may be good sensitivity
03:01:22to detecting the disease and to
03:01:24following whether your diseases your
03:01:26brain disease is getting worse but there
03:01:29may not be very good specificity
03:01:31differentiating the different diseases
03:01:33and I say that with a very big asterisk
03:01:36at the end of that sentence because
03:01:37there's actually amazingly cool new data
03:01:41one of our colleagues who you know Alf
03:01:45has helped revolutionize a new way of
03:01:47Imaging the retina that's giving us now
03:01:49cellular resolution and even subcellular
03:01:53resolution seeing things smaller than
03:01:56the sizes of cells inside our retina and
03:01:59recently in one of his projects he's
03:02:01teamed up with another one of our
03:02:02faculty Heather Moss she's a
03:02:05neuro-ophthalmologist so she really
03:02:06specializes clinically in the eye brain
03:02:09connection and her research focuses on
03:02:11that and together they made actually an
03:02:14amazing recent discovery of very
03:02:17specialized unusual novel structures
03:02:20that they can detect in the retina of
03:02:23patients with multiple sclerosis and
03:02:26whether these kinds of discoveries or
03:02:28other similar kinds of discoveries are
03:02:30going to lead to kind of a a whole new
03:02:32generation of biomarkers which are ways
03:02:35of measuring disease diagnosing who has
03:02:37the disease figuring out who's getting
03:02:39worse from the disease figuring out
03:02:41who's responding to therapies that we're
03:02:43trying to use to treat the diseases this
03:02:45is a very exciting area and this really
03:02:48touches on what we're all hoping is the
03:02:50future of of eye care as well as the
03:02:52rest of medicine and that's that's
03:02:54Precision medicine but also what we call
03:02:56Precision Health we really want to not
03:02:58just figure out what drug treatment to
03:03:00give this patient versus that treatment
03:03:01but we really want to figure out who's
03:03:04at risk of even getting some of these
03:03:06diseases and gosh we could intervene now
03:03:08and prevent them from ever getting in
03:03:10trouble in the future
03:03:12fantastic can't wait to hear more about
03:03:14those developments and listen I want to
03:03:17say on behalf of the listeners and
03:03:19myself just thank you ever so much for
03:03:22the discussion today I don't think I can
03:03:24ever recall a conversation that's
03:03:26included so much basic science and
03:03:28clinical science and also so many
03:03:30actionable recommendations both do's and
03:03:32don'ts as it relates to something so
03:03:35critical as Eye Health I also I was just
03:03:38reflecting for a moment
03:03:39about the fact that I think you and I
03:03:41met 20 years ago when you were a
03:03:43graduate student by the way folks
03:03:45um Jeff is uh sort of the Kobe Bryant of
03:03:47sorts although unfortunately still with
03:03:49us in the sense that he went directly
03:03:51from his MD and phds skipped his postdoc
03:03:55didn't require one directly to being a
03:03:56faculty member most people don't do that
03:03:59they do a five-year postdoc in between
03:04:00wait and then I believe he's going to
03:04:03tell me all the places I'm wrong and I
03:04:04should just come clean that
03:04:05um Jeff is my chair of department at um
03:04:08Stanford School of Medicine Department
03:04:10of Ophthalmology so for me I I see this
03:04:13as a particularly warming but also
03:04:16um at once unpredictable but pure
03:04:19pleasure of an experience to get to
03:04:21learn so much from you because I don't
03:04:22think we've had this long to sit down
03:04:23and talk science in a very long time so
03:04:26thank you for doing that for my own sake
03:04:30thank you for teaching us so much about
03:04:31how to take care of our Eye Health and
03:04:33now you can tell me where my history is
03:04:35wrong maybe my hippocampus is
03:04:36degenerating no it's been a pleasure
03:04:38over the years I have nothing but the
03:04:40warmest memories of of you as a postdoc
03:04:43and me as a graduate student getting to
03:04:44be you know nerds in the laboratory uh
03:04:4720 years ago 20 years ago at Stanford in
03:04:51the lab of Ben Barris and uh and very
03:04:53warm wonderful feelings about you know
03:04:56learning science and how to do science
03:04:58and making real advances even at that
03:05:00time and then the fact that we've had
03:05:01the chance to cross paths in San Diego
03:05:04again at Stanford collaborate on
03:05:07important projects having to do with you
03:05:09know developing new ways of measuring
03:05:11diseases developing new ways of treating
03:05:12diseases the idea that we're going to
03:05:15actually bring forward some of the
03:05:16advances that our lab that you're a lab
03:05:20that other people's Labs have been
03:05:21making in neuroprotection in diseases
03:05:24like glaucoma and macular degeneration
03:05:26in regeneration of the optic nerve of
03:05:29the retina we're real close on a lot of
03:05:32those this is a major topic of really
03:05:35The Cutting Edge research that we're
03:05:36really trying to keep pushing forward
03:05:38because we know it's so important to
03:05:40patients you know I I often joke you
03:05:42know my mother had a uh a sign outside
03:05:46the bathroom and it said remember how
03:05:49long a minute is depends on what side of
03:05:51the door you're on and I I really
03:05:54appreciate that like as fast as we're
03:05:56trying to go with our research and
03:05:57moving that into clinical research which
03:05:59I think we're doing very effectively in
03:06:01the department really working on Vision
03:06:03restoration research in the department I
03:06:06appreciate that as fast as we think
03:06:07we're going it's not fast enough for so
03:06:09many patients who are suffering from
03:06:11these diseases so thanks very much for
03:06:13having me on it's been a real pleasure
03:06:15reconnecting over these many important
03:06:17topics I really appreciate the chance to
03:06:19talk with you well delighted to do it
03:06:21and looking forward to doing it again
03:06:23you're an amazing colleague friend
03:06:25clinician and now public health educator
03:06:30thank you for joining me for today's
03:06:31discussion all about I Envision Health
03:06:33with Dr Jeffrey Goldberg I hope you
03:06:36enjoyed the discussion as much as I did
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