Welcome to the huberman Lab podcast, where we
discuss science and science based tools for everyday life. I'm Andrew huberman and I'm a professor of neurobiology and Ophthalmology at Stanford school of medicine. Today, my guest is dr. Jeffrey Goldberg dr. Jeffrey. Goldberg is the chair of the Department of Ophthalmology at Stanford University. School of Medicine. He is a clinician, an MD or medical doctor who sees patients every week as well as a PhD meaning a laboratory.
The scientist who directs his own laboratory focused at understanding the mechanisms and cures for diseases of the eye and vision such as glaucoma retinitis Pigmentosa and macular degeneration. Indeed, dr. Goldberg is one of the world leaders in developing methods, to cure blindness. He is also intensely knowledgeable about all things related to Vision. So during today's discussion, we indeed, cover, most, all of visual and I Health, you will learn for instance, about the benefits as well as draw.
Acts of wearing corrective lenses. Such as contact lenses or eyeglasses for reading, you will learn about the benefits and detriments of sunlight meaning how it can help your vision. In fact, how I can help reverse or prevent myopia or nearsightedness, as well as the things to be cautious about, with respect to sunlight in terms of development of cataracts, which are occlusions that prevent Vision. We also discuss many tools for maintaining and improving Vision across the lifespan rain.
Aging from behavioral tools. So specific Vision tasks and exercises for the eye that you can do. That are known to improve or maintain your vision as well as specific surgical procedures such as LASIK surgery. We get into all the details of, for instance, how often to do these various eye exercises, how long the benefits are maintained, as well as age-related considerations for things like, Lasik eye surgery, we even get into how to best clean. Your contact lenses whether or not to use disposable contact lenses or
Our forms of contact lenses. We also discuss things like dry eye and the best remedies for dry eye. And we talked about the scientific and clinical data around nutritional approaches and supplementation, based approaches for maintaining and improving Vision. So whether or not you suffer from floaters or dry eye. Or, you're considering changing your eye prescription, where you have concerns about whether or not relying on corrective lenses, is impairing your vision. And you want to enhance your vision or if you're somebody who has perfect vision, today's episode is going to include science.
And protocols that will be highly relevant to you. I should also add that if you are somebody who suffers from or who has family members who suffer from diseases of the eye that can impact Vision such as glaucoma retinitis Pigmentosa and macular degeneration. We also delve deep into the discussion about the most Advanced Technologies for preventing and offsetting vision loss, due to those diseases as well. Thanks to dr. Goldberg's. Incredible knowledge. His Clarity of communication and his generosity with that knowledge. By the end of
Is episode. You Will Be armed with all of the modern information you need in order to best maintain and improve your eye and vision health. Before we begin, I'd like to emphasize that this podcast is separate from my teaching and research roles at Stanford. It is however, a part of my desire and effort to bring zero cost to Consumer information about science and science related tools to the general public in keeping with that theme. I'd like to thank the sponsors of today's podcast. Our first sponsor is Maui. Nui, venison Maui Nui. Venison is the most nutrient dense.
Dense and delicious red-meat available. I've talked before on this podcast, about the key importance of striving to get one gram of protein per pound of body weight. Now when one strives to do that, it's also important to maximize the quality protein to Cal ratio. In other words, you don't want to consume a lot of extra calories in order to get your quality protein. Now, a new event assassin and having an extremely high quality protein and nutrient to calorie ratio allows you to do that very easily. And in addition to that, now, a new event has in is
It I particularly like their bone broth, which has an unmatched 25 grams of protein, per hundred calories. I also love their ground venison, and their venison, steaks. All of them are absolutely delicious. If you'd like to try Maui Nui, venison go to Maui, Nui, Venison.com huberman and get 20% off your first order again. That's Maui Nui, venison.com huberman to get 20% off. Today's episode is also brought To Us by element. Element is an electrolyte drink. That has everything you need. That is the electrolytes sodium magnesium.
I am and potassium but nothing you don't which means no sugar. It's critical that we get electrolytes because every cell of our body, but in particular are nerve cells or neurons rely on electrolytes in order to function properly with element. It's very easy to ingest the correct. Ratios of electrolytes, they come in these little packets. The really delicious. You mix them up with anywhere from 8 to 16 to 32 ounces of fluid. I like mine pretty concentrated so I'll drink a 16 ounce glass of water with element in it. When I first wake up I'll also consume another one of those
Be
32 ounces with one packet when I exercise, and maybe another one, if I happen to sweat a lot during exercise, or if I was in the sauna and sweating a lot, if it's a very hot day etcetera, if you'd like to try element, go to drink element, that's LMN t.com huberman to claim a free element sample pack with your purchase. Again, that's drink element element e.com, hubermann. Today's episode is also brought To Us by eight sleep, eight sleep, make smart mattress, covers with cooling Heating and sleep, tracking capacity. There's absolutely no question.
Kitchen. That sleep is the foundation of mental health, physical health, and performance when we're sleeping well and we're sleeping long enough. Everything in our daily life goes that much better. Now, a key component to getting a great night's sleep, is the temperature of your sleeping environment, and that's because in order to fall and stay deeply asleep, your core body temperature actually has to drop by about 1 to 3 degrees conversely. In order to wake up feeling refreshed your core body, temperature has to increase by about one to three degrees with eight, Sleep mattress covers, you can cool or heat your mattress.
The beginning middle and end of your night in order to optimize your night sleep. I started sleeping on an eight sleep mattress, cover about two years ago, and it has dramatically improved. The sleep that I get each and every night. If you'd like to try Aid sleep, you can go to eight, sleep.com huberman, and save up to $150 off their pod 3, cover eight sleep, currently ships in the USA Canada, UK select countries in the EU and Australia. Again, that's eight, sleep.com hubermann. And now for my discussion with dr. Jeffrey Goldberg.
Dr. Jeffrey Goldberg welcome,
thanks. It's great to be here
you and I go way back. We will spare people. The discussion about all of that. But I'm really excited for today's discussion because I get a tremendous number of questions about vision and Eye Health and course as a neuroscientist who has worked on the visual system I sometimes have answers or partial answers, but more often than not, I don't have the answers and yet I'm confident that you do or that. If you don't, you can direct us to the proper.
Get those answers. So to kick things off, I want to ask you, what was one of the most commonly asked questions? When I solicited for questions in anticipation of this episode, which is how early should one do an eye exam on their child and how regularly should we all be doing? Eye exams also is the fact that I think I can see normally confirmation that I can see as well as I think I can. So that's really three questions but
Baby comes out. Do they check their eyes right away? And if so how and how often should they check? And what kind of information is there?
Yeah, that's as a great question. It's obviously something that touches us all. So the question, the answer that really differs a little bit at the different stages of Life. First of all, every every baby gets an eye exam or should be getting an eye exam and one of the main things that you really just are screening for a right when that baby is born right in the nursery, right? In those first few days,
Just look for a red reflex, you know? And you take a camera picture, a Flash picture and sometimes you get red eye, that's actually the light from the flash, as you know, reflecting against the rat. And I'm coming back out of your eye. It looks red and and a red reflex is actually very normal. That's that that's great. And if you have another one of a number of diseases in the eye, that can present even in babies, even in newborn babies including most concerning, but thankfully least calm and
Retinoblastoma which is the most common pediatric eye cancer, which again, thankfully is quite rare. Those babies won't have a red reflex in that. I, it'll be kind of a whitish, or gray reflex. And so, even just that first little, you know, doctors taken the little pen light, and even just flashing it in that in the baby's eyes. So that's, that's, that's our first, I examine. And hopefully, we've all had that and hopefully every baby being born today is getting that getting that first die exam is really just looking for that red.
Reflex. It's not typical as long as that's looking. Good to worry about getting an eye exam from their kind of through childhood, like, maybe early Elementary School unless they built. Your baby is presenting with one of a number of features that parents often pick up on. For example, as the baby's aging through those first couple of years, you know, through the first couple of years, babies actually don't have great visual Acuity and so on.
As they're aging over those first couple of years. It's normal for them to have you know, roving eye movements. For example, be searching their environment. But over those first couple of years of parents start noticing the baby isn't, you know, isn't making eye contact or looking where a sound is? Certainly if they have what's called my stag mess, like these rapid flickering, alternating eye movements, anything like that. Of course you're going to trigger trigger an eye exam, but otherwise most babies other than
Our
pediatrician doing that red reflex. Check when they're in for the regular well-child checks. That's really all that's needed through that when most kids get to elementary school age, there will often be often done at the schools and amblyopia screening exam. If kids eyes either, if one eye doesn't see that well, like maybe you're very nearsighted or farsighted in one eye and pretty normal sighted in the other or the to refractive, errors are quite different from each other.
That can lead to a condition you've talked about on the podcast before called amblyopia, which is probably one of the more common or most common eye diseases of children. Or if the eyes are in a line, you know, our eye muscles and the Brain behind them are really responsible for keeping the two eyes looking straight ahead. And if that's not working properly and one eye is is off kilter and therefore the image of what we're looking at is falling on different spots of the retina, it's not sinking up right in the brain.
That can lead to this disease condition called amblyopia, wear that eye is no longer talking to the brain properly. And there's a, pretty easy, screening exam that can be done for strabismus. The misalignment of the eyes that kids will do in elementary school. The other main presenting symptom of kids in elementary school is when they admit to their parents, I can't see the board or I can't see the teacher up front and then they might be quite near-sighted and so that will also trigger an exam. And so those are usually the parts for for babies for
Slurs for children, school-age children that might reasonably trigger an exam,
a couple of questions about early eye exams and we'll get onto exams and older individuals in a second. But I want to interrupt you with this question. So you mentioned that there can be a misalignment of the eyes. I've seen many people's babies where there is one eyeball that seems to be kind of drifting around and then it might correct. But sometimes they'll have a, we don't want to get technical here, but for our listeners will keep it General. But yeah, they're converging.
Eyes or one eye, converging cross-eyes or wall-eyed, you know, again using non-technical language here. And my understanding is that the brain is taking that information in and is very plastic, it's changing in these early stages of development, and that it's fairly critical to get that stuff corrected early on. Because if you wait too long, the brain can essentially become blind to the the or rather, the the brain cannot learn to handle the proper alignment.
Alignment. So in other words, if a kid has a cross eyes crossed eyes, scuse me and they're not corrected until their 20s. It's possible that they will never recover normal vision whereas a few recover. If you align the eyes properly early in development, they can indeed recover Vision. How early can and should one consider getting those. I realignments
done. Yeah, yeah, pretty much right on. What they'll do is if they detect any, I misalignment and sometimes parents are are good at noticing.
Not as sometimes you take a picture and one. I got the red eye reflex in the other one didn't. And sometimes people notice that their kids eyes are sort of turning in on, it seems like too much sometimes, there's what's called pseudo strabismus, which is where, actually, depending on your Anatomy. If you have a little extra skin, sort of, on the inside corners of your eyes. It makes your eyes look turned in when actually they're straight. But if your eyes are actually turned in or slightly less, common in children, more common in adults,
It turned out, it's really important to correct that early. And the reason is, as you were saying, the brain starts, ignoring it fails to fully develop the strong connections from the for the data coming in from one of those two eyes into the brain. And if you pass certain sort of thresholds during development during childhood, without correcting that connectivity, getting those two eyes to work together properly. You can
Permanently lose that. And so we use sort of, we used to use very sort of, you know, gross numbers. Like it's fully correctable, if you can intervene before age 30, partly correctable, if you can intervene before age 60, you got a chance before age 9, but it turns out and follow on studies that even kids into their young teens, have a shot at correcting that I brain connection. That amblyopia, that that loss of vision that
That can occur during early development. So even if you're only, you know, unfortunately detecting that later on, in childhood, or even sort of the tween years or early teen years, it's still worth a try to really push to retrain the weaker eye. And then also realign the muscles, so that they can work together to keep the eyes focused. I'll tell you, it's interesting, and there's a lot more to learn about blank brain, plasticity. And probably a lot of
Cool new therapies yet to discover that could reopen what's called critical period? Plasticity? This, this this plasticity that we have during development the kind of goes away as we age and and that critical period plasticity as you know has been the best studied actually in the visual system and the idea that we could reopen that is really fantastic but for different parts of that I brain connection. There's different periods for critical period plasticity for example even if you
Get the amblyopia pikitis. See well again and then you realign the eyes and now they're working together. A lot of kids will never recover full depth perception, stereopsis the use of two eyes to see depth for example. So why that part of the brain doesn't correct as well as the visual Acuity or central vision part of the brain? I'm not sure if we understand
that, I'm gonna ask for a curbside consult as sometimes called right now, by telling you,
Story, when I was a kid, I went swimming without goggles and I had one eye closed and the other eye open and closing as it went in and out of the water, because I'm a deficient swimmer. And I only breathe to one side. Unless I really consciously forced myself to breathe to both sides in a freestyle swim. Got out of the pool and I was seeing double
It was pretty eerie and then it became downright scary because I didn't recover my double vision until they. Patched one of the eyes forcing me to use. The other eye that had been closed the entire time and fortunately, this was done early enough and I was young enough that within I think it was about a day or so, I restored what normal vision. However, my depth perception is terrible. I'm the kid that, you know, Fly ball was hit to me and
in the Outfield and it's coming coming and then it hit me. This is why I've generally focused on foot Sports throughout my entire life. As opposed to you know precise hand-eye coordination. I'm better at throwing darts and things with one eye closed than I ever would be. With both eyes, maybe that's true for most people. Question I have is,
Is it true that even just a few hours of misalignment of information to the two eyes early in development, can permanently rewire the brain. Unless there are some corrective measures such as patching up one eye and the example I gave is just one but for instance if you know, someone injures, the unit gets a scratch on the cornea and they close, they patch the eye and the person happens to be 10 years old. Is it important to them patch the other healthy eye? After the, you know,
the scratch die is feeling better. In other words. How critical is it to ensure the balance of information coming into the two eyes, even on the order of hours or
days? Yeah, your story is, it has some features of, you know, totally usual how we think about misaligned eyes leading to amblyopia. Where one eye is weaker patching, the strong eyes of the week, I can recover but not necessarily fully regaining depth perception. And so that part of it is, you know, quite
Eight stereotypical the part of your story. That's a typical is that for most kids an hour or two, let alone minutes an hour to even an hour or two a day if you were. I don't know if you were a young kid and you just really were training up on throwing darts and you were just keeping one eye close to throw the darts. You know, really practicing for an hour a day, it'd be very unusual
for that to trigger
this kind of either strabismus misalignment of the eyes.
As let alone amblyopia and the strabismus is what's giving you the double vision because they're misalign, let alone the ambulance,
amblyopia of one eye turning out weaker
if I had to guess, of course not having you know, done your exam before that fateful day in the swimming pool. If I had to guess, I would guess that you may have had some intermittent strabismus and your brain was already getting kind of hit and you neither you nor your parents may have even noticed it, it could be happening, you know, in other times a day.
You're
not kind of really paying attention, it doesn't kind of stand out in the
way, that that, that day, that you got out
of the swimming pool, you really noticed it, and it may not have been that strong. It may have been quite intermittent, but if you had had some years of intermittent esotropia or turning in of the eyes, or exotropia, turning out of the eyes that just happened here and there but was accumulating sort of damage or failure to connect over years, leading up to that day in the swimming pool and that day just tipped you over the edge.
And you've got double vision, you really noticed it that led to an eye exam at an eye care provider and they said, wait a second, this size stronger. This size weaker, you've got a little amblyopia, we're going to start patching your strong ice, you can get your week, I back. So for 99.9 percent of the kids who like, you know, yeah, they get a little cornmeal scratch or they're patching one eye closed or or, you know, and anything that's sort of a rare event like that. Nothing to worry about parents. Don't have to worry, kids can be kids, they can play, they can do.
Kind of thing. And and not have to worry. And, and it's unfortunate that we can't tell in advance, which kids been having the intermittent amblyopia, because we don't do a standard eye exam on every five year, old who's not complaining of anything. But, but yeah, so that's, that's an unusual case in yours. And if I had to guess, I would bet that you were having some sort of subclinical untracked Uncharted, unnoticed, maybe strabismus leaving up to that point.
Okay, great, thank you. You can
send me a bill at the end along those lines. I'm 47 years old. So I was part of the generation that grew up with some computers in the classroom but not a lot nowadays kids from a very young age are looking at iPads and phones and screens and things very close up and there is a wealth of experimental animal data showing that if you limit Vision to just close range.
That the eyeball lengthens and therefore the visual image Falls in front of and not directly onto the neural retina, the essentially, the light sensing portion of the, of the eye and those animals become myopic or nearsighted. What can we say about the environmental conditions in? Which kids are seen from the time? They're born through? Let's say adolescents and their teen years in terms of how they're visual.
System wires up and are there any recommendations that are coming from the scientific literature? Clinical studies, clinical trials, scuse me or otherwise that indicate what healthy visual environment consists
of? Yeah, that's a great question and I actually it's really relevant these days because, you know, myopia is so common. It's more common.
In Asian populations, you know, it's called an epidemic in China in California, we have a lot of Asian, Heritage, or Asian Americans. And so, we see a lot like at Stanford. We see a lot of, you know, myopia in kids, and adults and really starting to get thoughtful on the science of myopia control. How do we, how do we provide the right environment? Now, what's interesting is that for decades, the Assumption, some of the
Data really led us to the path of thinking like gosh the more you spend at near activities and these are Mouse model experiments like you describe but also well design human cohort studies, you know, figuring out like asking, you know, kids and families. Like how long is your kid reading or in front of the computer? How myopic are they? How nearsighted or they versus how much time is your kid in front of the computer doing near work, how myopic or nearsighted, or they. And these well-designed cohort studies did
The point torwards this concept that if you do too much near work, as a kid that you're more, likely to develop nearsightedness, as you get through those, those sort of, you know, preteen and even into the teen years, which is when most of that myopia progression or eyeball elongation is actually happening to cause nearsightedness, it's only been in the last few years that some really exciting. Studies have actually pointed in a slightly different direction.
And that's that maybe it's not all not to say, it's not about near activity but maybe it's not all about near activity. Maybe it's actually a little more about the kind of light, we're getting into our eyes and I think you've talked about this before and it's really important when they've now studied and ask the kids instead of just how much near and how much farther are you doing? How much time are you spending indoors in indoor lighting? Which doesn't have full spectrum, light and a typical indoor environment versus how much time are you spending Outdoors?
Playing in the yard, you could be reading outside. But what are you doing? What kind of time are you spending outside? And and and of course when you're outside in sunlight, even it's in direct sunlight. You're getting a different spectrum of kind of Full Spectrum, Lighting from the sun and it looks like it's pretty clear. Now actually that it has maybe more to do with outdoor lighting time than just near work. And so I think that, you know, we've actually already
in the first couple randomized controlled trials, where they're having kids intentionally spending time Outdoors versus sort of Standard Life which you know is going to be often much more indoor time and and seeing some effects you follow those kids over a couple of years and the kids who spend time Outdoors are are progressing in their nearsightedness last, like their their nearsighted prescription is not getting as strong as the
They are spending more time indoors. And there are some pretty good biology. That's getting worked out. Going back to animal models more about about how that might be working in the retina in this inside the eye. But it's pretty compelling concept and and so, you know, as a parent you may want to be, you may want to be telling your kid. Like, okay? Yeah, I want you to read that book or, you know, I have your kids plan on the phone or something like that, or the iPad or something like that. They're allowed that time. Okay. You can have that time.
But I want you to spend some of the time that you're doing that
Outdoors. Are there any thresholds for the amount of time? That one would suggest their child be outdoors to get that full spectrum light?
That's a great question. You know, we talked about cohort studies, where we just ask people, what are they doing? And there seems to be you know a little bit of what we would call a dose-dependent response. May be the more time Outdoors might be better. We don't know if there's an upper limit like gosh if you go over 2 or 3 hours there's no additional benefit talk about that in.
Cohort studies, the real gold standard for answering these kinds of questions are randomized, controlled trials and specifically placebo-controlled or a control group. That's not getting the intervention. That's our highest level of evidence for clinical evidence, for any of this kind of science when we're talking about humans or preclinical models in the laboratory, and the study that hasn't been done yet to really answer that question is to randomize kids to
This group of kids, you just do your normal life. Tell this group of kids, we want you outside an hour. This group of kids, we want you outside two hours a day. This group of kids, three hours a day and see between the groups. Is there a big difference? Like we have pretty good evidence. Now from the studies that have been done that the difference between 0 & 1 or 2 hours is clearly. There is five minutes. Enough is five hours better I don't think we know the answers to those questions yet. Like what's the right?
Right dose but there's probably at least some dos dependents to that
and it can imagine it's a little bit hard to tease apart the near far viewing from the indoor-outdoor because yes, of course, a child could be outside on an iPad up close, but it's hard to imagine that some point they aren't seeing off into the distance far viewing as it's called and the reverse is also true if you're indoors unless you live in a very, very large home or you're staring off a balcony, far viewing is much harder.
To achieve. Yeah. So it's and perhaps it isn't important to isolate these variables, although I can see the challenge in developing, a really good clinical trial randomized, clinical trial for this. Meanwhile, I, you know, I'm constant, I'll go into the grave shouting, you know, or saying, rather, and suggesting that people get some morning sunlight in their eyes to set their circadian rhythm. But far viewing a few, at least a few minutes and ideally hours per day or a mixture of near and far viewing by being outdoors. Just seems
A good thing to do, regardless of age. So are there any data in older people? Not necessarily elderly but older people. So I'm people in there from say 25 years of age into their 60s or 70s that getting outdoors, and getting this full spectrum. Light is healthy for the eye in ways that are separate from the known healthy effects of doing that on circadian. Rhythm
setting. Yeah. Yeah. The Circadian Parts, pretty clear. The and most patient in most in most people than the
It meant of nearsightedness happens, a lot until age 10 little more through age, 20 little more than that into the in you know in through the 20s up to 30 tiny bit in the 30s up to 40. But usually by those later ages, your prescription might be changing a quarter of a diopter. That's the measurement that we use. When we you know give you your glasses prescription quarter of a diopter half a diopter, it could get a half diopter more nearsighted or less nearsighted
And you know, once your aging into your 40s, 50s and Beyond, so most of the action on nearsightedness development is actually really happening in the younger ages. So again, the, the premise of intervening in an older person and I'll just include you and me and older people for the sake of this definition, as much as I'm reticent to do that in general. I think the premise of in, of sort of light modulation for nearsightedness in older people as probably,
Probably not so strong. I think there are a lot of other benefits. You've talked a lot about circadian rhythm. There are so many health benefits to exercise and, you know, if you're getting Outdoors, there's a good chance you're going to be walking or bicycling, you know. So so exercise value for the health of our eyes and the rest of our body is clearly there, but I don't know that there's really a strong premise that you're going to change your glasses prescription, you know, in our 40s or 50s or
Beyond. I'd like to take a quick break.
Take and acknowledge one of our sponsors. Athletic greens, athletic greens. Now called a G1 is a vitamin mineral probiotic drink that covers all of your foundational nutritional needs. I've been taking athletic greens since 2012 so I'm delighted that they're sponsoring the podcast. The reason I started taking athletic Greens in the reason I still take athletic greens once or usually twice a day, is that it gets to be in the probiotics that I need for gut health. Our gut is very important, it's populated by gut microbiota that communicate with the brain. The
System. And basically all the biological systems of our body to strongly impact, our immediate and long-term health, and those probiotics and athletic greens are optimal and vital for microbiotic health. In addition, athletic greens contains a number of adaptogens vitamins. And minerals that make sure that all of my foundational nutritional needs are met and it tastes great. If you'd like to try out, let it greens. You can go to athletic greens.com huberman and they'll give you five free travel packs that make it really easy to mix up athletic greens.
While you're on the road in the car, on the plane that cetera and they'll give you a year supply of vitamin D3 k 2 again. That's athletic greens.com huberman to get the five free travel packs and the year supply of vitamin D3 K to probably worth touching on some of the do's and some of the don'ts for Eye Health generally. And then I promise, I'm going to get us back to adult eye exams because I have a lot of questions about that.
I can imagine that it's probably not a great idea to be exposed to extremely bright light in, this is why people who weld where I Shields. But of course most people are not welding what other sorts of environmental conditions are detrimental to our vision health across the lifespan including brightness of light. We talked a little bit about near far. Obviously we want to keep toxins and acids and solvents and things out of the eye, but what do you see
I'm like, hopefully not commonly but what are some of the things that you feel might not be discussed enough in terms of Eye Health?
Yeah, you know, I think at all ages. I safety is something that we don't talk about enough. You know our eyes are delicate. The front surface of the eye, the cornea, the Clear Window that lets the light go into your eye. That's a delicate very sensitive structure, its thin, maybe a millimeter at the thickest half.
Mm. In the center of our eye. The retina is its neural tissue. This is like really an outgrowth of the brain. This is very sensitive. It's subject to degenerative, disease, and injury. Our eyes. Even if they just get hit can get very inflamed or eyes, can be more inflammatory than a bruise on our skin, on our shoulder might be, so I safety is a big one and people who are working in certain industries, you know, anyone is doing any metal.
Dang people who are even just gardening, you know, and if you're if you're doing some significant gardening and cutting and you could, you know, Flack a little bit of dirt and, you know, there's a lot of there's a lot of for example fungus that lives in the ground natural stuff. It's all very normal in the in the Earth, but, you know, our eyes aren't really made to absorb that fungus and have have a piece of dirt kind of stick in our. I like that. And so people are at risk. I think for, you know, for not and we see too much kind of
really unnecessary, eye injury eye, trauma that if people were either their glasses because they happen to wear prescription glasses or goggles or for more advanced work, you know, safety goggles of course, if you're sanding doing Woodshop projects, anything like that sawing, including, you know, again in the garden, cutting things, you know, I think, I think I safety, you know, I trauma is a big one and
You know, we probably see one or two, what we call open Globes a week, come into the Opera into the emergency room and, you know, those are tough because, you know, again the eyes delicate and it can do a lot of healing, but, but not infinite, right? And so we really, you know, that's that's one that I think is really an untapped opportunity as just a little more education around around eye protection protecting against I
I
trauma. What about I cleanliness? There's some pretty dramatic videos. Also, I've put some of these on my Instagram handle of these are MRIs of people rubbing their eyeballs. And people really getting a sense of first of all, a restatement of what you said, getting a real sense of just how much the eyes are an outgrowth of the brain because of the opt one, you see in with the optic nerves and all their beauty and the eyeballs moving around as someone rubbed their eyes. I have to imagine that rubbing your eye balls. A little bit isn't bad but actually called you. I don't know if you remember when
I was a junior Professor. I woke up from a nap one day and I couldn't see out of one eye that's freaking out. So of course I called you and I had pressure blinded Myself by falling asleep, on my hand or something like that. And you assured me that my vision would come back and indeed it did. So you play a dual role of ophthalmologist and psychiatrist. Thank you. And indeed I can see out of both eyes now
but
rubbing our eyes getting gunk in our eyes. You know. I think unless somebody has
Lost their Vision. Temporarily, it's hard to imagine. This is like a big deal but when it happens, it is truly frightening. We're so dependent on Vision. So you know what are your recommendations about rubbing or not? Rubbing eyeballs about hand washing and cleanliness and also, how do you wash? And I properly. Do you use soap and flush it with water? Or do you just flush it with water or she not even do that? She use saline. I didn't realize these might sound like low-level questions. But these are the things that people deal with on an all too frequent basis.
Yeah. You know,
Most people most of the time actually the eyes are a very good clean environment and actually our tears are our contain enzymes that help break down bacteria and bacterial toxins. And so for most people regular I washing doesn't have to be any part of their standard routine. In terms of the surface of the eye, the part of your eye, the conjunctiva over the whites of the eyes underneath the islands. Anything underneath the eyelids, it's pretty self cleaning and actually are
Our tear production and blinking is very good at keeping our eyes clean. The eyelids eyelashes can be another story and especially as we age we can, you know like our skin is breaking down a little differently than when we were younger. You can develop what we sort of nickname scurf which is like kind of little dead skin bits. That accumulate around the eyelashes, a lot of people develop what we call blepharitis which is just just means inflammation of the eyelashes. Yeah.
And for that, doing some I scrubs as a good idea, they actually sell a little pads that you can buy the kind of little that you rip open and you can use to kind of lightly clean the eyelashes. But you can also just use like a No More Tears. Baby shampoo, just pump a little bit into the palm of your hand once or twice a day. Let a little dilute it with a little water and under the sink. And either with your finger or an edge of a washcloth just very lightly rub, the eyelashes, what I like to
do to TI's,
Close with the
eyes closed and don't scrunch them close to type because you're actually burying the eyelashes when you do the roots of the eyelashes, when you really scrunching us. So just gently close your eyes, just, you know, real gentle closure and then just lightly scrub, it shouldn't be abrasive. You're not trying to exfoliate the eyelids or eyelashes in any way just lightly rub with that kind of dilute, No More Tears, baby shampoo and that can really help people with their iComfort. If you feel like you
Something in your eye, your ideal. I wash is actually going to be a sterile saline solution, a saltwater solution that you know they sell little bottles over the counter. I wash Solutions like that. A lot of people wear contacts will have that kind of, I wash solution, just a sterile saline. I wash just pure salt water. Doesn't have to have any other chemicals or preservatives in it. You can, of course, use on
actual sea water, or saltwater
saltwater. Thank you. Yeah. Not so,
Water out of your salt pool not salt water out of the ocean but like a saline salt water that's available in a sterile. Now you could also just use artificial tear drops and some of those come in non preservative. Some of those common preserved versions. Those are all also completely safe in the to use in the eye. And there you can, you know, you can sort of Spritz into your eye, you know, hold the lid open and give it a little Spritz. If you feel like you got something in your eye piece of dirt or A Lash that's not coming out just to rinse it. But, but having like a regular
Our routine, you know, you're not going to hurt anything with the occasional. I robbing we all do these things just kind of as a, you know, even a nervous habit or just absent-minded lately, you know, you might, you know, scratch your arm or rub your eyes or things like that. That's fine. You're not going to hurt anything. There are conditions where people sort of develop, kind of a almost like a psychological habit. There are certain conditions where people actually do too much eye rubbing. It can be dangerous if you're in that group, but for the regular run,
Of the mill. Everyday, occasional eye, rubbing fine. If you're certainly, if you get a lash in there and you're trying to rub it blanket and tear it out. And again, in that situation, you can use some artificial tears, wedding drop saline drops. Those would be the way to do
it. What an incredible tissue, the way you describe it, you know, the self-cleaning and yet, so delicate, the piece of the brain literally lining the back of each of our eyes, like, like a pie crust. I mean, it's a really remarkable.
Well, the biological system of course I don't have to tell you that it's just it it never ceases to amaze me. Let's talk about eye exams in adults. So people are aware presumably that there are optometrists and ophthalmologists. I think it's important that we Define their different and also overlapping roles and for those that you know, our past High School age, probably not getting eye exams unless they're sensing a problem.
Not even with blurry vision or difficulty seeing at a distance. But sometimes, just what feels like fatigue of the eyes or a hard time, maintaining alignment of the eyes. So how often do you recommend people get exams? What is a true regular eye exam and is it important that people go to an ophthalmologist or will an optometrist suffice typically optometrists are a little bit easier for most people to access because there's usually one someplace near an eyeglass store. So what are their roles, how often should we
Our
eyes checked. Yeah, optometrist and ophthalmologist do have very overlapping roles
in being. I care providers.
There are something over 40 or 50,000 optometrist in the United States. There's somewhere around 20,000, ophthalmologists in the United States. Optometrist get an optometry degree. They often have OD after their name, ophthalmologists usually went, you know, went to medical school. So they either have an MD after their name.
Or they kind of a
Deo version of a medical degree
and and then optometrist will have done additional clinical training in that are in their area of, I care provision ophthalmologist MD, doctor ophthalmologist Eye Care providers. In addition to that training will have done a surgical training in Ophthalmology. Now, there's a lot of overlap and in both scenarios, you can be getting your
General exam taken care of maybe a screening exam. I think that there's been a traditional differentiation between optometrists and ophthalmologists with optometrist providing a little more of the primary care. I screening may be managing early disease, common diseases, as well. With more advanced disease often sort of upgrading to perhaps specialist ophthalmologists in those areas.
But that distinction has been declining over time. It's still true that in, I think most, if not all states. Only the MD ophthalmologists surgeons can do eye surgeries. But both both groups of I compare care providers. Can diagnose, both can prescribe appropriate? I drop treatments, including prescription eye drop treatments for for many of our diseases I diseases and and
Some states optometrist have successfully lobbied for sort of expanded rights of providing are care. I care and again, access to care for, you know, the regular person wherever they may live is is the most important element. And so being able to access I care whether it's with an optometrist in your community or an ophthalmologist that maybe in your community or maybe at a distance. I think that's the really important thing is to access care.
Are now kind of like we're talking about with kids, if you're in your teens 20s, maybe even 30s, I'm not having any problem. You've got no complaints, you can see a distance. You can see it near, you know. So you can read without glasses, you can drive without glasses. You're not having an AI. Pains, you know, pains around the eyes, you know, redness of the eyes, you may never present to an eye care provider.
Through the first four Decades of life. And almost all the time, it's going to be, okay, right? If you're not symptomatic, the chance you've got some terrible, lurking disease in there is low but we do wish that we had a little more screening going on because there are some diseases glaucoma for example, my specialty, the two main risk factors for glaucoma are increasing age and it usually presents, you know,
Most cases actually after age 40 but also increasing eye pressure and if your eye pressure is too high, you can't feel that that won't feel funny to you if it's sort of slowly as crept up over the years. And so from a screening perspective, it is good to get some kind of screening exam could be at a public health. Fair could be that you go into the local optometrist just say, hey, I've never been checked. I'd like to be checked once. Make sure everything's good. Could you ask for a sorry to interrupt? But could somebody say
I'd like my pressure?
Check as I recall the optometrist are going to do a puff test. So they're going to blast some air, get a sense of how rigid or soft again using non-clinical non-technical language here. The eyeball happens to be that right now. By the way, I'm sure there are several hundreds of thousands of people who are with eyes closed touching the sides of their eyeballs and I'm only half joking. Please don't do this folks given the conversation we just had about, I cleanliness and I rubbing, but my understanding is that the old fact truly old-fashioned. I press
Sure. Exam was you would close your eyes and they ophthalmologist would gently press to see whether or not your eyes were more rigid than last time. Is that right?
That's called balat mint. And you can kind of you can, you can kind of just take one second. If you're listening and press on your eyes just very lightly and you there's a little give of course, the eyelids part of that give. But, but it's not, it's not like rock hard and if we press and it feels under the eyelid like, gosh, something under. There is rock hard. Then we know something is wrong. That is way.
To high pressure of its rock-hard. But I'll tell you our ability to differentiate the fine points of eye pressure, other than Rock Hard or not, rock-hard is pretty limited. So yeah, the optometrist office or the ophthalmologist office as part of a comprehensive screening exam. They'll check the eye pressure, the look at the surface of your eyes, make sure everything's looking healthy there, including the eyelids and lashes, and the look inside the eye, and be able to screen for these diseases that way too. In addition,
To checking if you're complaining of any, you know, blurriness at distance or near now after age 40 or so, a lot of people will present to an eye care provider because we all get what's called presbyopia and presbyopia, just translates to disease vision of the agent. So, you know, myopia is our word for nearsighted. Hyperopia is farsighted actually emmetropia means normal sighted so I can see it.
Distance without any glasses. I'm emmetropic.
But then we all get presbyopia. And as we age the lens inside our eye, that's helping focus light onto our ratna gets stiffer. Such that our eye muscles are no longer able to relax and reshape that lens and were not as good as we age at moving. Our Focus from distance Vision, distance Vision. By the way, is basically anything three feet or further away. You're basically viewing light rays coming from.
From Infinity at once you're past three feet. So three feet are further being able to focus that into 14 inches or 12 inches, which might be a normal comfortable reading space for you. We lose that ability to flex our lens, relax our lens, refocus our lens from distance to near and most people around age 40 could be a couple of years before it could be five or ten years later that you notice it but sort of around that time you start needing
Glasses, you need a little extra but even if you can see fine at distance and don't need prescription glasses for distance. You need a booster, you need reading glasses for near. I don't know if you're experiencing this
yet. And yeah, I'm really intrigued by this. But maybe you could clarify when you say reading glasses, do you mean just a magnifier? Because I use a, you know, a .5 or 0.75 magnifier for reading, but I try and rely on them as little as possible. And I want to get to this about using glasses as a
Touch and the problems with that. I have a story about that too. I think, you know, it's it's no coincidence. I decide to work on Vision. I mean, after all a bunch of vision issues that fortunately are corrected. But, you know, I, I do experience for instance, when I wake up in the morning, if I look at my phone, which by the way folks, I try and get outside and see some light first before, ever looking at the phone. But I'll notice when I first look at my phone in the morning that I can see it very clearly through my right eye.
But that if I cover my right eye, my left eye is extremely blurry to the point where I'm like I'm calling Jeff you know I'm afraid but then over the course of maybe 10, 15 minutes, it resolves and I don't think it's because something's in my eye, I don't think it's pressure of having slept on that side. I don't think it's a lubrication of the eye issue, but the to I seem to come into Focus. So to speak at different rates early in the day. And if I pop my readers on, I can see right away. So, I will use readers late in the day off.
Even if I want to read at night or something. That's alright, just, it feels so much more relaxing. I feel like if I like I can finally relax. Whereas otherwise, I realized that I'm straining in order to see does, is there any clinical clinical data and what I just
described? Yeah, I'll you know, and I'll tell you my story, that's like that. And we were living down in San Diego. When you and I were both professors at UC San Diego and we had moved into a house. And I found a pair of glasses.
A pair of reading glasses in a closet. And, you know, we asked around, you know, did any of the grandparents, leave some glasses behind, nobody seemed to know who they were. So we finally just decided like, well, I guess the people who moved out of the house, just left a pair of glasses, you know, in this in the back of this closet and then I tried the glasses on and I looked at my phone up close and was just like, oh my God, wait a second. I didn't realize how blurry my near vision.
Asian was and this is back. I was about 40 42, something like that. So so I didn't even realize until I put on the readers and these were, you know, 1.25 magnifiers, you know. So also
Mi fairly mild ones. Yeah.
And I'll Talia
I got addicted because who doesn't like good Vision right? I mean oh my God. Now I can make the type smaller on my phone. I can you know is wonderful. You can relax a
bit. I think that musculature that's responsible for removing the lens and focus in the eye and then all this extra ocular musculature and we forgot mean, I'm definitely going crow's feet around my eyes probably because I squint or something. But you know, just the ability to relax one's face. It's just feels like, you know,
Or
more energy. I feel like can be devoted to what we're actually looking at not making light of this. Yeah,
well pretty soon. I just kept that one pair of glasses with me all the time and I would just keep them in a pocket and whip them out. Whenever I was, you know, working at near using my phone had a little greater distance, like a typical computer distance, I could still see the computer finds it really started for like kind of that close-up phone. It was, it was I could get into here but not all the way into here and yeah. And then pretty soon. I was just
Totally addicted. And so, you know, then I had to go buy 10 pairs and leave them one by the bedside table. You know, one in the car, one in the computer bag, one on every desk, I work at. Yeah. Because I'd leave them anywhere and forget them and that way, I could just, yeah, exactly. You know, so yeah, so whether using the readers accelerates the progression,
Of dependence on the readers is still not, you know, it's still up for debate, you know, some studies say maybe, yes some studies say, maybe no. But certainly psychologically, we get addicted to good, easy vision. And if you don't have to squint and you're if you're not straining your muscles and all of a sudden the text on your phone looks crisper again boy, that's addictive. You're going to like good vision and so it feels like you're getting.
Dependent and how much of that is change in the eye muscles and how much of that is just the psychology of wanting to have good Vision. I think probably the jury's a little bit out on that point. But point being you're either either way your dependents will grow and as you continue to age 40s 50s up until about 6065.
The ability to chap, that lens, gets weaker, and weaker, and weaker. And so you need to move from the point five to the one point owes to the 1.5 sand,
get a coke bottle to the code. Well,
thankfully not you eventually max out at about plus 2.5, or plus 3, because that's the amount of extra refractive power that you needed magnifiers to take the equivalent of your Infinity viewing and bring it.
To 14 inches to read it near basically, you need a plus 3 and then you don't need any lens eye muscle action whatsoever. So you kind of max out around 2.5, S, or threes, so because most people will hit this somewhere in their forties. This sort of like, gosh, I'm having trouble on the phone. I think most people actually use that, that's like, kind of the first time for a lot of people. They're like, well, I guess I
Go to the I office, right? See the optometrist or maybe ophthalmologist and when they go in they should be getting the standard in. Either of those offices will be to give you a full screening exam including maybe it's the puff test or a blue light test or a little pain that can check your eye pressure and having a look inside. And seeing if your retina and optic nerve look healthy, it's kind of screening for all the main diseases. And so and they'll tell you at that point, hey, you look great. If you have
I like your glasses aren't doing it for you in a year or three years, come back or they might say, hey, I've detected something I'm worried about you and they'll set up a routine for your ongoing. I care
assuming that somebody doesn't have, you know, some form of amblyopia or the need for some really robust corrective lenses.
And they are already using readers, let's say a plus 1 or so, plus 1, plus, or minus 0.5. Reader would you recommend based on my experience and based on your experience that people strive to avoid using them for as long as they can? Because in some sense, if that's the recommendation, then the recommendation is that people kind of deal with the fact that they're seeing a little less well or a lot less well than they possibly could. So I'm assuming that people can still drive. Well, people can
still read, but it involves a little bit more effort. In other words are we weakening Our Eyes by using these these readers. I realize you said that the data are a little bit mixed, but as long as one can perform their required daily activities, would we be better off delaying? The use of readers,
there's two important answers to that question. One is regarding the lens and the eye muscles that control the lens and it's entirely plausible. That's what I was saying. Kind of the data.
Next time. But it's plausible that if we were just exercise like work a little harder kind of not used as strong a reader as we want or not use that reader as often as we might really enjoy. Are we exercising those muscles? And kind of exercising, the ability to stretch versus relax, the lens and kind of slow the progression from the 1.0 reader to the 1.25 reader to the 1.5 reader at
Cetera, right? And so that's why I saying the data is mixed, but there's a good premise that maybe if you're exercising, but let me give you the on. On the other hand, it's probably ideal to give your retina and your brain, the sharpest, visual signals, you can. So why hamstring, your retina, and your brain and your vision, and your enjoyment and ability to read or do near work.
By constantly undercutting the, the reading glasses or leaving them out, or you're not helping the whole back part of yours, maybe your, maybe you're helping the lands, but you're definitely not helping your retina and brain by feeding it blurry information, all of that time. So I actually think just give in use the readers. Have your bed, enjoy your Best Vision all the time.
And if that means wearing glasses, and by the way, if that means that, you're going to have - two glasses for vision and you'll eventually need - to 50s for distance Vision or if you're going to need readers, 1.5 readers. Now in a few years 2.0 readers. Okay, so you'll get the next reader. It's actually not a big deal. You can, you can, you know, you're not, you're not hurting your probably helping and in the meantime, it's an enormous enjoyment to actually have good.
Good Vision all the time, right? So so I actually counsel people
just wear the glasses that work best for you. You know, you're only minimally changing how your prescriptions going to change over time very minimally. So just enjoy your Best Vision. Even if it's using readers for clothes or prescription glasses for far,
appreciate that recommendation, I do enjoy YouTube using the readers at night. It really helps for all the reasons I mentioned before.
I've noticed that driving at night presents, an enormous strain on my visual system, and I've noticed this for a number of years. There any, I know, there's something called stationary night blindness, I don't think I'm stationary night-blind. I think the mutation for stationary night. Blindness was identified in the Colusa horse or something like that. These were horses that you could walk up to very easily and they won't even see you until you were right there. Someone's going to correct me on this. It's the internet, but it's I think that the mutation was identified Etc, but I don't think I'm stationary night.
And, but I do find that driving at night. I get very fatigued one. And then, I'll sometimes even wear my plus-one readers when I drive at night, which removes the fatigue, even though I'm looking more or less at a distance, are there some conditions that make it hard for people to see at night, for which they would want corrective lenses? And what, what sorts of biology underlies that assuming that somebody is not stationary night, blind or Colusa? I think is the name of the breed of
horse.
Yeah, that's a great question. You know, we for the, for the optical defects in our eyes, most, or many, of which can be corrected with just having the right prescription lenses, we can get away with it without using those Corrections in brighter light and so during the daytime, you know, you could be slightly blurry, you know? If I have a real bright light and a good high contrast book, you know,
With black letters on the white page. I can get away with reading that without my readers. Unlike if I'm a dim light then I feel that might be kind of what you're describing. If you're reading at night, you actually prefer to use the readers a little more even at night because we can make up for a lot of that blur. If we just have bright enough signal and contrast coming into our eyes sense. Yeah. So when you're driving at night and noticing this, this might be revealing a little bit of a need for glasses.
Says, now I'm not suggesting, this is the answer, but far more common, than having congenital stationary night, blindness would be being what's called a latent hyperope. Okay. Now, we talked about already how the lens inside. Our I goes from focusing at distance to, then we squeeze the muscles, the lens actually rounds up, and it allows us to focus it near some people's Optical system of their eye. Is actually wired or
Designed or sort of setup in length, not for regular distance, which would be anywhere from about 3 feet to Infinity. But it's actually designed it's actually tuned for being beyond Infinity, which doesn't make any actual sense when you talk about it. But just the Optics of the eye at their best, Focus are actually focusing the light behind the retina and and if you're doing that when you're younger, you're actually using some of your focusing power too.
Use those muscles strain, those muscles relax, that lens Roundup that lens, and have your vision Focus From Beyond Infinity to normal distance, like distance vision. And so, if you're a latent hyperope, you are constantly using those muscles. And again, if you're tired, it's the end of the day, your muscles are feeling a little fatigued, your latent hyperopia, or by the way, if you've had a drink or two,
Alcohol can do this to your latent. Hyperopia can kind of kick in especially as we're age and we're not as good at refocusing that lens anyway. And now all of a sudden your vision is kind of reverting to its natural state, which is slightly out of focus at distance because it's actually focused beyond Infinity if you will. And so all of a sudden you put on that plus one, just for a little extra booster kick and you're like, oh yeah, yeah, distance vision is clean and easy now. So,
I'll have to bring you into the clinic to really, be sure. But you could be exhibiting a little bit of that kind of late in hyperopia
definitely want the eye exam, and I want it from you and I've been called a lot of things in life and we can now lat add perhaps latent hyper opiate to that. I'd like to take a quick break and thank our sponsor inside tracker. Inside tracker is a personalized nutrition platform that analyzes data from your blood and DNA to help you better understand your
body and help you reach your health goals. I've long been a believer in getting regular blood work done. For the simple reason that many of the factors that impact your immediate and long-term Health can only be assessed with a quality blood test, the problem with a lot of blood and DNA test out there. However, is that, they'll give you information about certain lipid markers or hormone markers, but no information about what to do with all of that data inside tracker. Makes it very easy to look at your levels of hormones. Metabolic factors, lipids, Etc and then to assess what sorts of Behavioral
You know, supplementation or perhaps other interventions, you might want to use to bring those numbers into the ranges that are appropriate and indeed optimal for you, if you'd like to try inside tracker, you can visit inside tracker.com
huberman and get 20% off any
of inside trackers plans. That's inside tracker.com huberman to get, 20% off another piece here. And again this discussion is not designed to be an eye exam for me, but I have yet another experience that I think illustrates the key importance of
Both critical period plasticity and the questions about whether or not to rely on corrective lenses and that is from the time I was pretty young. I could make my sister laugh by deviating one eye inward. So not crossing my eyes but moving one eye Inward and then what happened was when I was in college and studying a lot a lot and getting very fatigued. I notice that this I started just kind of drift in a little bit so I went to the campus Health Center and they gave me a prescription for a Prizm lens which
Course, redirects the image. But then I noticed that this eyeball moving Inward and I guess, for those of you watching on on YouTube and not just listening, I can do this by just moving one. I in, all right, as I can move, this lie and say, yeah, it's a fairly pronounced. It started to really drift in at a relaxation State, and I started seeing double again. So I thought, whoa, these prism. This one Prizm lens lens as a crutch of the sort that I really don't want crushed the glasses broke them and never went back to them.
I have voluntary control over it but that's one example where the corrective lens can actually create a pretty significant shift. In I position, if one relies on it, so we just gets back to this issue of. When should people Force themselves to work with their natural vision? Maybe do some more far viewing as opposed and certainly get outside and get sunlight into the sunlight full-spectrum light as opposed to relying on corrective lenses.
Yeah, and you've raised a very important distinction here
And that's the distinction between the muscles that are inside our eye that we use to relax and refocus the lens and the muscles that are on the outside of the eyeball, of course, inside our orbit. But on the outside of the eyeball that turn the eyes and if everything's working right, keeps our eyes really you straight. And we talked about earlier this possibility, that you may have been having a little bit of intermittent. He's a tropea or intermittent turning in of the eyes that then
Culminated on that day of day at the pool. When you really noticed it and your ongoing ability to actually turn, one eye in, could be related to that. I remember as a kid standing in front of the mirror or not, I couldn't get my eyes to cross even though friends could do it. And you know so you know II was in the losing group on that on that end of the spectrum and
off the foliage and then I became an optimal which and I must say it is very reassuring that you have excellent Vision, you know, I always worry when I go to a new dentist and I look up at them and one moment and if they're not
I am a that their teeth are not, you know, Christine I think, well, what am I doing here? So, you know, and an ophthalmologist with excellent Vision. Get brings me great comfort but cobblers children should have shoes. Right? Exactly. But yeah, so
so when to correct, when
not to correct with lenses and I realize here, we haven't talked at all about contacts. We've been talking about eyeglasses.
Yeah, let's come to contacts in a sec if you want. But yeah let me return to your question the difference between providing corrective lenses.
That allow you to focus for near or distance in your glasses, so that you can go easy on the inside the II muscle having to work so hard, a lot of people get eye strain and sort of headaches. Even from that, from not having adequate correction, that they're wearing, that's different actually, especially when we're children or again into that maybe even into the teens and even young adult years from the eye muscles, on the outside of the eyes, which are supposed to be yoking our eyes.
Rate and so that you have them both working at the same point in space. And and there it's actually quite a common treatment to try to under correct. And ask people to exercise and not just give a prism that says, hey if your eyes in some time, we'll use a prism, so the light sort of looks right to you. But rather under correct that and sort of really force you to exercise. Trying to yoke your two eyes straight together. And so that's, that's in
contrast. And they're actually, I think many optometrists who often specialize in what are the right glasses to give in a situation like that wherever possible, especially during development as our bodies are developing, as we're sort of growing in our younger years. Take the approach of intentionally trying to under correct. Not use a prism or not, use a full prism correction and to really help.
Up. Sometimes it's also like an accommodative reflex that your eyes are just. You're spending so much time. Reading it near when you read it near your eyes. Actually naturally, turn in a little bit to focus at that near so that they can be looking at the same word on the page and that can also, if you've got kind of too much muscle drive, you can overshoot that. And so sometimes just using not a prism but like a little bit of a plus lens in kids just so they don't have to work quite so hard to turn their eyes in and sort.
Of extra over exercise, those muscles. These are all great examples. We're going to and I care provider often for these kinds of issues and optometrist is the right first place to start. You'd like to say that every optometrist and every ophthalmologist is always going to give the exact right thing for each kid or young adult or older adult to do. And and we wish all medical care providers were were always right on Target and a lot of times it's a perfect science, but a lot of times it's an imperfect science and so
It could be that at least with, you know, we're now 20, 25, 30 years later. But like, it could be that today that 20 year old version of yourself would have been given a different approach to having one eye intermittently occasionally turning in like that. Is
there any real value to near far exercises? You know, so-called pencil push-ups or smooth Pursuit tracking. I've talked a little bit about it before on the podcast, but that was some time ago. So what are your
Oh, thoughts on on that. Is there any value whatsoever? I mean, they require a little bit of work just like going to the gym but, you know, you know, 25 reps a day of near far, especially as one is transitioning from age 30 to age. 50 is it worthwhile? Yeah. Is it harmful in any
way? Definitely not harmful. And again, you know, would it slow down or sort of slow down your progression to presbyopia or needing those reading glasses, could be some
Also, develop sort of, you know, a real failure to properly turn their eyes in and so, they actually would benefit if you've been diagnosed with that inability or having double vision at near but not at distance. So, that kind of convergence insufficiency. For example, then then pencil push-ups off and get prescribed as a way to try to exercise those skills and, you know, in your eye muscles,
I should interrupt here and just tell people for those of you,
They're listening, not watching the pencil, push up. We can put a link to it in the show notes caption, so it's essentially taking a pen or pencil looking at it at at arm's distance and then slowly moving it towards your nose and deliberately working hard. And it is a bit of effort to continue to focus on it at a close distance. At some point, it will become blurry because I can't cross my eyes, any further, unless I become a cyclops and then moving it back out again and doing that for, you know, 10 to 25 repetitions, Maybe
Sir twice a day a few times a week. That's what those are pencil.
Push-ups. Yeah so you're certainly not going to hurt anything. There are other situations where those really do get prescribed and there's definitely some good clinical trial data suggesting that they can actually help for example, recovery from concussion. A lot of people actually, one of the really telling ways to diagnose concussion and this can be concussion from sports or a fall or you know, any any
A source of concussion, your smooth Pursuit which is the ability. Let's say I've got a DOT moving around in a circle on a screen and I'm following that thought with my eyes, my eyes should be able to very smoothly follow that circle around the really doubting my
eyes. Lock on one watching a hockey game is
that like your wife Andrea? Like, thanks, you know, just following a ball. You know, following any movement with smooth Pursuits of your eyes and after concussion that actually those systems in our brain.
The sort of reflects of ability to properly follow that. Use that visual input. Tell your eye muscles exactly where to move gets disrupted. And so, all of a sudden, you're smooth Pursuit starts to look choppy. It's not so smooth anymore, and it's actually a way to diagnose and follow recovery from concussion. And part of the visual rehab sort of neuro rehab, one of the approaches being used and further studied still in recovery. From concussion is a
Actually doing those kinds of exercises like pencil push-ups or basically. What you've described is focusing from far away to focusing near and doing that back and forth. And using that to sort of like help regain the tighter control of our eye movements and that I brain connection. So, if traumatic brain
injury causes deficits in smooth Pursuit, eye movements and some of the recovery protocols for traumatic brain injury are to have people do smooth Pursuit, protocols, and pencil.
Shops are these also the sorts of things that anyone can just do? I mean, whenever possible, we like to share tools for various aspects of Health on this podcast. But of course, we don't want people cowboying this stuff in a way that could be detrimental to their to their Vision. So is it okay to get on YouTube and find a smooth Pursuit tool? We can put a link to these. There are several of them and people spend a few minutes doing this. Yeah,
you're definitely
Definitely not going to hurt anything so totally fine to do it. And some people may notice, you know, like they feel a little more visually active. If they do these kinds of exercises, I think most people would do them and not notice something in their daily life. We actually have made so much progress. You know, in research in thinking about how do we take the disease door dysfunctioning or aging? I
And get it back to healthy and normal. But there's a whole other area of science. That's, we're really just barely touching. We've actually, we've actually just opened a vision performance center to really get at not. Just how do we rehab the sick? I back to health. But what's the difference between functioning normally and functioning above normally? For example, athletes when they get studied for,
Excellent Vision characteristics, they have faster visual reflexes higher visual Acuity, how much of that was, you know, genetic how much of that is trained? We don't really understand. Can we train all of us with, you know, normal vision, to get up to Supra normal vision. These are like great and important questions that are really relevant to. You know, every regular person, of course, you know, people doing Esports in The Gaming Community,
And athletes is part of what we're studying in the vision performance center but these are really, really big opportunities to try to understand how do we move people from normal vision, to supernormal vision, and there's evidence that you can do it. So here's a great example, some athletes train using these special goggles that actually use electrical signals in the glasses, part of the goggles to actually blackout your vision 1/30 of every
Second to thirtieths of every second 3/30 of every second now, imagine you and I are passing a basketball back and forth except you're wearing goggles and all of a sudden, you're only getting 90% of the data of. Where's that basketball on its way to my hands. Now you're only getting 80%. Now you're only getting seventy percent of that visual information, and you are practicing, right. You are getting good at catching a basketball. When you only have a fraction of the visual,
Formation and now I put you back on the basketball court without the goggles. What you might be really good at passing that basketball around and catching that basketball, right? And so the idea that we could train and understand the biology of training to get the eyes from normal to supernormal, Performance is an amazing area and one that we've really just started to dig into.
That's fantastic. So this is a new program at Stanford through the department of ophthalmology.
Homology, is it linked up at all with the Wu Tsai performance Institute?
Yeah, actually there's been a lot of focus over the years, I think, in human performance and there's actually a new human performance Alliance and Center. We've long had really run through the department of Orthopedics, a human performance laboratory. That's really, you know, much more about joints and muscles and strength, and conditioning and stretching to layer on to that.
Now a real understanding of how vision is operating, you know, it's interesting. Let's go back to the example of concussion. You know, we've got I don't know about 800 varsity student-athletes and all the different sports at Stanford and you might have a student athlete come in and say, you know, something doesn't feel right. I got a little hit on the head. I feel like my vision is a little bit messed up. Maybe, I've got a mild concussion, you could imagine doing some of these tests on some of these
It's athletes for example, and saying. Well gosh, you look normal, but actually they used to be operating at a super normal rate and this is a noticeable decrement for them. And so just starting to study and understand what's the difference between normal and super normal? How do we go back and forth between those two? How do we measure that difference and maybe ultimately how do we train into that difference? I think it's going to be exciting and not just for athletes, you know, for regular people. You know, you talk about
At night, is there a solution where we could train our eyes to be better at driving at night? And I don't know, maybe reduce the number of accidents that happen out in the world. So, we'll
certainly there's physical training protocols, which are redefining what a 60 year, old or 70 year old could look like and feel like and be able to perform like, why not do the same for vision. So I don't think there's anything Supernatural or a greedy about doing it. I think that's the excitement of biology and
Plasticity that you can extend it forward as opposed to just trying to wire up correctly during development. This is a perfect time for me to ask you a question that I'd love a clear answer on. If it's possible, it's not always possible which is could you define 20/20 vision and a few of the variants so that any person could understand it. So we think of 2020 as perfect vision. What does that mean? What would degraded Vision look like?
Whatever those numbers are. And then what would above-normal Supra normal vision look like? Yeah. And is it true that fighter pilots have Supra normal vision?
Yeah, that's another population. Like like like many athletes of people who may have sort of better than normal vision 2020, you know, we Define almost everything we do based on, you know, kind of a average, not sick, human being
Adult whatever it is right? And so 20/20 vision means that you can read the smallest letters at 20 feet away. That the average healthy person can read at 20 feet away so you can read it 20, what they can read it, 20, okay? Now if you have worse than 20/20 vision, maybe you've 2025 Vision, 2040 Vision. Maybe you've 20/200 Vision, which on the eye chart at the office is like that.
Oh, Big E at the very top as 20/200 Vision. That means you can read at 20 feet, what a normal person could read at 200 feet, right? So you've got pretty limited lower Vision, we can measure down to like 2428 hundred at that point. We're getting into. Like gosh, can you count how many fingers I'm holding up, you know, that kind of thing and then ultimately hand motion. Can you even tell if my hand is
Moving in this side of your vision or this side of your vision. And then, ultimately, after that light perception, can you tell if the room lights are on or off, right? And that's kind of the edge of being actually fully blind. We call Legal blindness in the United States, typically 2200 or
worse. And is it true that there are people who are legally blind that are out there driving as we're having this conversation? I I
have to imagine that that is unfortunately the case, but it should be because those people
Obviously, our really severely impaired and and that's obviously quite dangerous. So, so so that's 2020. Now. It gets worse 2040, 2080 20100. Can it get better? Yeah, it turns out that people can be sort of on the other end of that curve and so we could have athletes and fighter pilots or people who have had LASIK surgery, who are 2015 2010. If you're twenty ten, that means you can see a 20 ft what the average.
Person needs to be only 10 feet away to see, right and so you've got better than normal vision and people do get to that through a variety of ways and so it is possible to have better than 20/20 vision.
Does the degree of visual Acuity because that's really what we're talking about here. Differ dramatically between the 2 oz
in most healthy people know, you know? Remember, we talked about you're born with something like 22.
200 Vision. Takes you a couple of years and it can be a little bit
asymmetric 20/200 Vision. Yeah, that reminds me, I've seen images of what babies can see your parents loved looking at their child and thinking of their child is looking right back at them. And indeed often the child is looking right back at them and your face to your child, sorry to break this to you, folks is incredibly blurry even at that close distance for probably the first six to eight months events before you come into sharp relief. They're not seeing the fine details of your face. Yeah. So
Big. That's right spot, very good, keep those eyebrows dark
trite and keep cooing at them because they can hear pretty well, that's right. Yeah, the Optics of newborn babies are just dreadfully, bad. Yeah. But they need visuals to
now other species not you know, Hawks Raptors owls that hunt. They can naturally have 2010 28 Vision, right? So much better vision and that's just their normal vision as best as
Has been measured. So so there's definitely the potential for us to have better than 20/20 vision. Now all of this we call Visual Acuity and just to be clear for everyone that's the vision in the very center of your vision. Like when you're reading or looking, that's the very center of your vision. Our vision is actually described variably as a hill of vision. The peak is in the center, that's let's say 20 20 in most people, right? But it's normal to have that slope off.
And our visual Acuity, your ability to read the eye chart on the edges of your vision. If you can read the biggie, that's pretty normal. Like you would be 2,200 out on the edges of your vision and we would feel like yep. That's pretty normal. So so our highest Acuity Visions in the center and that's a big part of why we spent a lot of time using those eye muscles to look around, right? We got to, we got to get a little bit of a high Acuity view of what's around us, fill in fill in the gaps of what our what our brain is.
Is is interpreting our peripheral world to look.
Like it's almost like we have two visual systems. We have a high Acuity, High pixel density, camera in the middle and then surrounding that is a pretty low resolution, but very fast detector camera. Yeah, Yeah, you mentioned Lasik, but I want to make sure that before we talk about Lasik that we talk a little bit about contact lenses, is
there any
detriment to having a piece of glass or a piece of plastic on the front of your eye all the time? And the reason I ask is not because
so I think we should live necessarily exactly like our ancestors but it's a pretty bizarre adaptation to put a lens directly on to the front of the eye. You have to imagine that the cells and tissues, there are accustomed to getting a certain amount of oxygen. There's somebody getting a certain amount of interaction with the environment and and you also are now adding another surface. The way that the tears are going to interact with the, you know, with the cornea of the eye or probably change and who knows? Maybe it doesn't make any
- difference at all but, you know, putting a contact lens on the front of the eye is, you know, about as close to putting a device on your brain. As I can think of except for, maybe the cochlear implant. Yeah,
that's a great question. Now, first of all, I want to distinguish there are a few really medical uses for different kinds of contact lenses. Like scleral, contact lenses for people have certain diseases. There are other kinds but
I think what we really want to talk about right now is just kind of the run-of-the-mill. I want to get my prescription taken care of, but instead of wearing glasses, I'm going to wear contacts contacts, even the newest generation contacts. Yes, they sort of changed the tier Dynamics on the surface of your eye. That they, they decrease the oxygen, you know, diffusion that's just sort of out in the air onto the surface of our ion to the cells that are
Surface of our eye, but most of us especially as we're younger. Have enough tear film Reserve enough oxygen Reserve that we can easily tolerate. These polymer, gel, soft contact lenses and wear them, happily the advantage of contact lenses over glasses, purely, from the perspective of correcting your vision, is that there's different elements.
Elements of, of the shape of your eye that need to be corrected, if you need corrective lenses. And so, for example, if you're the basketball shape of your eye is a little too steep or a little too shallow, that's what the standard glasses. Correct, you may have been told that you have something called astigmatism. That's where instead of having a basketball shaped by you have a slightly football-shaped die. It's not round in the
Same dimensions on both axes and again, glasses can correct that but then there's higher-order aberrations in our corneas in the clear window in the front of our eyes or to some degree, in the lens, inside the eye, that are focusing. The light that the glasses prescription can't correct. But if you have a nice smooth contact lens on the front, it can correct. So a lot of people who wear glasses and contacts will report that they have a much higher quality of vision with
Are contact lens correction than with their glasses correction. And again in service of enjoying the best Vision that you can enjoy in your daily life, that's an upside to seeing if contacts could work for you. Now, there's another element though and that's like, gosh, is there a risk of contact lenses? And especially as we age, we have less tear film reserves or contacts. May become less tolerable as we age.
And the other thing is being really good about the cleaning because, you know, the contacts can trap bacteria or fungus. And if you get a corneal infection from a contact lens, it actually can be quite devastating to your cornea. Even if you successfully treat the infection, you can be left with some corneal scarring. Thankfully this happens, very rarely but when it does happen, it can be quite difficult on, you know, on the person thereafter to sort of suffer through having maybe a scar from that and
Affection on the surface of their cornea that they that leads to some blurring vision, for example. So we always recommend that if you're going to wear contacts that, you be really attentive to whether you're tolerating them. Well, and then also to be really attentive to the recommended use and cleaning of the contact lenses. I actually recommend that, even though they're a little more expensive to afford that people should almost, always be just using the daily contact lenses that they don't have to clean.
Either use for, you know, two weeks or four week period. So these are
disposable contact daily
disposable and I hate to think of, you know, I don't know, filling our oceans or what-have-you with more more more polymer plastic but at least the contact lenses are small and it's much safer for your eye to use a daily disposable than to use a two week or a four week and be responsible for the cleaning. The other thing to be really responsible about is sleeping in the overnight, because overnight, when your eyelids are,
Clothes, of course. Now you're getting even less oxygen to the surface of your eye, actually, most bacteria, especially many of the Infectious bacteria to our bodies. And to the surface of our, I are actually bacteria that don't really like oxygen. And so we've got a low risk of getting bacterial infections on the surface of our eye. But if we use contacts too much, don't clean them or sleep in them overnight when our eyelids are closed. And now there's even less oxygen kind of helping keep the surface more
Clean, if you will, that increases the risk a lot. So being really good with the recommended use and cleaning of the context is critical considering daily use contacts. You don't have to and look most contacts are going to be the two week or for week kind where you put them in the cleaning solution overnight. Each time give them a good rinse and put them back in the next day. And I got most people 99.99, some percent of people are going to do just fine with that follow the instructions and never get into trouble as we
Age, they're going to become less tolerable. People are going to say, I used to wear my contacts for 12 hours. Now my eyes feel really dry after six or eight or ten hours. Maybe some years after that, there's a gosh, I can barely use it for four hours. I only use them when I go out on a Saturday night and and that's okay. You can, you can, you can back off as you need to back off. But, in the meantime, if it helps you especially in the younger decades, if it helps you really enjoy your Best Vision. Great.
What about UV protection in eyeglass lenses and or contacts? I've dealt with many questions about blue light. I am not somebody who believes that all blue light is terrible. I think it's important to avoid Bright Lights of any wavelength late at night. If you want your melatonin production to be normal and you want to sleep well doesn't matter if you're wearing blue blockers or not. If you're just under blasting Lee Bright Lights, it's going to suppress your melatonin and yet some people enjoy blue blockers for that reason. Nowadays a lot of
Of people wear blue blocker, glasses or blue blocking lenses or contacts throughout the entire day. Thinking that blue light is bad for our eyes. During the day. I happened to subscribe to the idea that we want as much bright light, as we safely can tolerate during the day, ideally, from sunlight, in order to set our circadian rhythm and yet a lot of eyeglasses and a lot of contact lenses out there have u-v-a and or UVB blocking features to them. So what are your thoughts on this? And I'm perfectly happy to be wrong. And revise, my
My stance on this. Yeah. What do you think about this u-v-a be blocking?
Yeah, it's a it's really important to distinguish that UV light on the light spectrum is right next to blue light, red lights on the other end. Of course, infrared is beyond that and our eyes other animals can see these, but our eyes can't see infrared. That's why we call it Beyond red and we can't see ultraviolet. It's we call it Beyond Violet UV. Light is
Is right next to Blue Light UV light is known to have a lot of adverse effects. It's not really good for our skin and therefore, you know, we really want to avoid Sunburn and kind of you video, you know, exposure and damage on our skin. Similarly, it's not really good on our eyes and it affects both the ocular surface, a little bit in terms of like kind of how dryer irritable your eyes might feel for some people and certainly over the long term UV light will accelerate
Formation of cataract, which is a blurring of our oxidative blurring of the lens inside the eye. Profound UV light can be damaging to the ratna if you're getting way too much on the inside. So so blocking UV light, I believe is just absolutely standard in every pair of eyeglasses and I don't know, actually how much to what degree the different kinds of contact lenses. Also filter at least UV light now.
Blue blockers, blue blocking, glasses as totally different. And as I say, like, I think, almost all glasses because the Plastics almost all glasses are not made of glass anymore. They're made of plastics, but I think almost all of them now filter the UV light, which again is like, probably the safe move for our eyes and Perry ocular environment around the eye environment. So blue blockers, you know, that's been a huge fan. I'll tell you the last three years through the pandemic.
Buddy, getting on their computer hours in front of Zoom meetings where we used to walk from building to building for a meeting things like that. You know. I remember you know, like the sort of big uptick in these kinds of questions and I'm not sure that there's any data that blocking blue is helpful in any way. And as you say, it may actually play into sort of circadian entrainment of our natural daily Rhythm. So
So I think blocking UV is a good idea, and I think it's pretty standard, you know, they make glasses by the way that actually react to UV light, they're called transitions. There may be a few different brands, I don't know. But, you know, these are the sunglasses that are clear, except then they turn dark if you're out in the sunlight and it's not just any sunlight, it's actually the UV wavelengths, that that caused the chemical reaction in the glasses to turn from from Clear see-through.
Two sunglass, blocked glasses. And you may notice if you if any of you out, there are using these kinds of glasses that they don't work in the car, you'll wear them in the car and they won't go to sunglasses. Even though it's sunny out. And again, that's because all standard car glass, also filters UV. That's why if you're riding around in the car and it's sunny out, you've got your hand you know, up next to the window, wearing a t-shirt, you never get a sunburn through the car window anymore because all
Our car glasses also filtering UV light for us
so so that's a very informative answer. And before we started recording you and I were discussing this practice of morning sunlight viewing which again I highly recommend over and over and you pointed out that low solar angle sunlight, so, sunlight low in the sky viewed for maybe 10 minutes or morning. And again, not forcing oneself to look at it and stare, but blinking as needed is not going to cause this extensive UV damage to the eyes.
It's really the when the sun is directly overhead that we're getting a lot of UV which raises this other question, which is for people that don't wear corrective lenses. And therefore are not blocking UV light to the eyes. What should they do? Are they in trouble? Should they be wearing a
brimmed hat brimmed hats? A great idea that I'll get a read of a lot of the direct light into the eye. Of course you still have reflected light off of surfaces and that that
can include UV light, of
course, you know, wearing sunglasses
Outside. Even if you don't have corrective lenses, you know, it's may also be more comfortable to wear sunglasses outside. So so these are all fine, you know, at the end of the day, it's probably not making a huge difference in the health of your eye. Whether you've spent the last 50 years, wearing sunglasses really dogmatically for your outdoor time or
not,
you know, if you were going to develop, let's just say age-related cataracts inside your eyes, which will all get caught if we all live to 120, we all
Cataracts, you know, it's going to happen. Some people younger, some people older. Maybe if you were really dogmatic about wearing your uv-blocking sunglasses. Maybe you'd get your, your cataracts at 75 years old. Instead of 72 years old. It may not be a huge difference in that regard. So, again, not something to be super stressed. I think it's, I think it's more a question of just, what are you comfortable in? And then certainly, I will say the, the other advantage of a wide brim hat is it's keeping sun off of your face and these are the you know, some of the
Especially the upturned portions of your face, like the cheeks and the knows these are the some of the most common places to get some of the skin cancers that you can get over a lifetime of sunlight exposure. So, you know, the wide Brynn hap is, is it's helping you for that as well
can't help. But ask about Comfort at varying levels of brightness. I'm the person that when sitting in a cafe or something and on a bright day I can be directly across from somebody. Like you who seems to be perfectly fine without sunglasses and maybe even more shaded under
Growl or something that's or and I'm squinting like crazy. Is it normal for there to be a wide variation? In sensitivity to light? And does this have anything to do with the lightness or darkness of the eyes? You have brown eyes? I have green eyes, but is there any real correlation there?
Yeah. You know, it's a good question. I don't know if it's been formally studied, but I will tell you, like, I have the same impression you do, which is that if you have a blue eyes or light colored eyes, that you're more likely to have more
More sensitivity. We know that there's differences in the iris muscles that constrict and dilate in response to light. For example, when you go into your eye care provider and they're going to do a dilated exam, and they put the eye drops in your eye that dilate the eyes, they sort of change the nerve impulses on to the iris muscles of the iris dilates, and you get those big big open eyes people with blue eyes. We absolutely no blue or Hazel.
White colored eyes, you put that I drop to dilate their eyes, it's going to last for 68 hours, whereas in a brown eyed person often the dilation only last one, to four hours. So there's clearly biological differences between the irises and their muscles and maybe the nerves that feed those muscles between light-eyed people and darker eyed people. And that may also therefore relate to this, differential sensitivity that some people
Have you know, if you're not able to constrict your eyes in the bright light as effectively, you're going to find that bright light more frustrating, more annoying, you know, even painful people feel like their eyes are cramping almost as they try to get that those eye muscles to activate to bring down the pupil and block some of that excess light from getting in. Interesting,
let's go back to Lasik what is LASIK? And should I get Lasik eye surgery?
Does it, does everyone need Lasik? Can it help every can it make us, you know, super physiological, you know, can it make me a 2010?
You know often it can I'll just say that you know right up front and is amazing. People will come out of way. Sick surgery a better than 20/20 but the cornea we talked about before. That's the Clear Window on the front of your eye. All the light has to get through there and we talked about before already, like if your cornea is misshapen, if the basketball shape of it is too too shallow, or
Or too steep, then you're going to need glasses to see it distance and also at near if it's to football instead of basketball, then it's going to be what we call a stigmatism and and then you can't you need a correction for that instead of correcting with glasses that sort of helped shape the light. So it can go through your slightly off shape cornea instead of wearing contact lenses which also shape the light just as its entering, your cornea right on the surface of the eye.
You can just reshape the cornea and the way Lasik does that. There's a few different versions of Lasik, but basically, the way the Lasik does that, is it actually a blades or gets rid of a little ring or rim of that corneal tissue. So that, for example, if you were a little shallow and you got rid of a little bit of that tissue around the edge, with the laser, the way is Blazek, you know, starts with the word.
Laser, if you got rid of that edge tissue, then you're sort of making it a little more basketball shaped, right? Or if you were too steep on your cornea and you use the laser to kind of shave off a little bit of the tip of that basketball, right? Then you're flattening it out, flattening out the cornea. So it's that kind of reshaping and the technology has come so far that the Lasik procedures can actually correct. Not just the regular aberrations that we
About but also some of these higher-order aberrations and there are different monikers for this kind of Lasik, it's all I think become fairly standard but wavefront guided where it's actually using light waves to measure with a very exact localization exactly how much and where to laser for each individual. I to make that cornea past the light as ideally as possible. Now one or a few percent of patients will actually have a dry eye problem. So,
After lasik. Because though, it does interfere a little bit with those corneal nerves. For example, and I do think that, if you're a person who already has dry eye, hopefully, if you're asking your eye surgeon about Lasik, hopefully, you're being counseled that if you have dry eye, this might not be a good idea for you. Just like contacts, might not be a good idea for you. If you already have a lot of dry eye, but for a lot of people, especially a lot of younger people, it's quite common. I think the statistics are just maybe 15 or 20%.
People who would benefit from LASIK, you know, who would be, who would otherwise be wearing? Glasses may get Lasik at some point in their life. And, you know, I used to joke, you know, LASIK cost more money than a pair of glasses, but it doesn't cost more money than 10. Pairs of prescription glasses over the course of a decade or two, you know. And so I used to joke that gosh, if everyone had to have laser eye surgery for their best vision.
And someone came along and said, hey, I've got invention. You don't have to have laser eye surgery anymore, it rests on the ears and the bridge of your nose, I call them glasses. Could they have sold those for a thousand two thousand dollars a pair? I don't know maybe. But you know, there's kind of a cultural element of saying, you know, like, I don't want to wear glasses, you know, I'd love to be able to walk around without relying on glasses or contacts, of course. People are very athletic or spending a lot of the, to their time doing Athletics. They may be quite irritating.
Didn't have to deal with glasses or contacts people who have very severe prescriptions. I mean, if you wake up and you can't even really, you know, you're fumbling for your glasses on the bedside table because you have such a strong strong prescription. You can't even see what it says on the alarm clock next to the bed. You know, these are all groups of patients who like really change their daily lives by getting out of glasses or contacts and taking advantage of Lasik. And in I don't know 99%
Scent of the time. It's going to be like a safe comfortable outcome for the
patient. Do they do? Lasik on
kids, there are certain conditions unusual cordial conditions, where procedures like Lasik at used. But I believe it's ideal to not do it on children, or even even young teenagers and the reason goes back to what we were talking about before you are much more likely to change the shape of your eye. The
And therefore the prescription you need and therefore what exactly the Lasik would laser, while you're still in those growing years. And you really want to be able to say, hey my eye glasses prescription has not changed in the last two or three or five years, because if you do Lasik and then your eye keeps changing shape, then by the next year, all of a sudden the lakes that Lasix not doing your back in glasses again, right? You can do a touch-up Lasik do a little bit more.
But it's generally, you know, you're going to be a happier person. If you've reached that point in your life and maybe that's maybe that's your late teens more. Commonly it's into the 20s where your eye has stopped changing its prescription. Every year you've been steady and stable for some years and now you do the Lasik and it could easily last, you a decade.
You mentioned dry. I get a lot of questions about dry eye. And a few years ago, I think you and I were at a meeting and someone who is very woven in with the companies that build and test drugs, for different aspects of vision. Health said, you know what the field really needs is a treatment that works for dry eye and I thought dry, I like of all things like why dry? And then the more I learned about it, I realized that there are millions
Millions of people that really suffer from dry eye and for whom standard drops are just not working. So what underlies dry eye is it some deficiency in the lacquer won't glands that produce tears for the eye. And and I think of Tears is just kind of salty water and I wonder if they are more than that. Is there an oil in there and if we know what's in tears, why can't somebody just manufacture something that works as well as tears?
Yeah, you know, it turns out, you know, we've got a lot
Two other eye diseases but by far the most common eye disease and I've been told by far the most common eye treatment, you know, purchased by anyone. Now granted, it's almost always over-the-counter things like artificial tears is for dry eye and in part that's because as we age, our tier quantity goes down and our tier quality goes down. And so what are those? Two mean,
We have two different major elements to tears and as you alluded to one is the salt water Port of part of the tears. And those are made primarily by the lacrimal gland. And there's a steady drip of those tears onto the ocular surface, as well as reflexive tearing, right? If you get an eyelash in your eye or, or you cry or you're like them. Old, Randall actually squeeze out extra salt water tears, onto the surface of the eye and so so that's that's where most of the sort of wet part is coming.
Going from but there's also essential oils critical oils. These come from other types of glands including glands in our eyelids called my booming glands and the oils form a surface. Over the salt water, part of the tear film and, and also intermix into the tears. And as we age, we go down in the quantity of both salt water part of our tears and oil part of our team.
Is but also the quality and in particular, the oil parts can often be seen to be going down more quickly. The the I drop industry has pretty much solved for replacing the saltwater part of your tears, right? You can get either bottles of preserve preservative containing, you know, you could use that bottle all month or for a month or two or you can buy these strips of
Of free artificial tears, which are really basically, like the salt water component, and you can use those preservative free ones. We have patients using them every hour. If they need to write, you're not going to hurt anything with preservative-free artificial tears. You just drop them in. Just drop them in. Yeah, either I as often as you want or need when you feel it, it's exacerbated in the world, we live in.
Especially these days. Now, with more time on computer, it turns out that when you read including when we may be used to read more books than we do now, but also read on the computer or stare at the computer screen or work on the computer or actually just even watch the TV dunce, very careful studies, you blink less when you're doing any of those activities and when you blink glass your redistributing, the tears less effectively and you are squeezing out
Less of the tears including less of the oils as effectively as you could be when you're blinking. And so so between aging, tier quality, tier quantity, a lot of our activities were kind of in this losing proposition now. Now I mentioned that we're pretty good at replacing the wet salty part of our tears but actually as an industry we haven't really figured out a how to really effectively replace the oily part.
And the oils do a few things. Including when you have a layer of oil on top of a layer of water, the water is less likely to evaporate and so the oils help, hold the tears on the surface of your eye. And so if we're not making as many or as good oils as part of our tear film, that's that's also, I kind of worked in against a saltwater, part of our tears. So yeah, as an industry as a community, that we haven't really figured out how to get
Oil parts of far either by effectively replacing the oils or treating our eyelids in a way, kind of rejuvenating those oil glands getting them to kind of go back to their youthful State again. You know. So the the eyes including the islands in the oil glands, unfortunately their aging just like the rest of our body. So so this is this this is one of the major features is is dry eye and and it's tough on patients because
you feel it. It's really tough because you feel it.
I have yet another experience to report where when I had the blepharitis which fortunately was transient. I also experienced that every time I blink I could feel the blink. And boy, I'll tell you we all most of us. Take for granted what a pleasure it is to not. Observe the blinking of our eyes because for those I think it lasts about two weeks every time I blink at feel an almost sandpaper-like
Experience. It wasn't particularly painful but it was very uncomfortable because you suddenly conscious of every blink and it's very distracting. Now that resolved when the blepharitis resolved, but I can't even imagine what it would be like to deal with that all day long, every day, really
Dreadful? Yes, it really is. And, and so, you're absolutely right. It's a very, it's one of our really big unmet needs and, and although, for most people with dry eye, it can be managed with just the regular over-the-counter artificial tears.
Drops. You can buy at the grocery store or over the counter at the pharmacy for a subset of people who have really much more severe symptoms with the dry eye. It's really, it's hard. It's a really hard thing to have to live with all the time and and we Counsel on the use of Tears, we Counsel on the use of eyelid cleaning. Like we talked about before where you take either these eyelids scrubs or a little dilute baby shampoo to keep those eyelashes, really clean. That keeps those oil glands functioning at their top capacity for you. So that
you
Maximizing, you know, high quality tear production. Reducing inflammation is also important, whether that's inflammation from allergy and of course a lot of people's dry eye. Gets much worse in the spring with seasonal allergies. When pollen is around, if you have dust allergies in your home that worsens your symptomatic, dry eye or other forms of inflammation. There's a, there's an element of dry eye. That we actually think is inflammation kind of working against
Our tear glands and and in fact, some of the prescription drops now to help combat more severe dry eye are anti-inflammatory or even low dose steroid types of eye drops. So, I think these are all sort of next-generation treatments. I think at the at the really Leading Edge of Next Generation treatment is trying to better understand the nerves on the cornea and ocular surface. And if there are ways that we could better treat them and help help regenerate and
Juventud, kind of how the nerves, and the, and the tissue cells are interacting underneath that tear film. And that's where, for some patients, we can actually use either, for example, blood serum. Your blood serum is actually very rich in growth factors and many of those growth factors. It, turns out empirically are really helpful for people with dry eye. So if you're one of those people who's been really struggling with with dry eye, you might ask your eye care.
Or hey, I heard about serum tears. Is that something that could help me. Serum tears. Serie is this PRP is this platelet-rich plasma at related but but not the plate route. Platelet-rich portion? At least not. Yeah, they can draw your blood spin out all the cell's. You're left with the kind of liquid part of your blood, that's the serum and then they can dilute that with some salt water, maybe with some preservatives. In some cases, you could keep it in your freezer, thought the bottle, when you're ready to use it, you know, each other a few weeks.
And and then use it just like an eye dropper bottle and those serum tears. Actually can be very helpful for people with with much more advanced or severe hard to control dry eye symptoms companies are really trying to figure out. Hey, what are the most important parts of the serum? Can we just identify and package, just the growth factor and and turn that into a product for dry eye patients? As there's a lot of research on the ocular surface, and
Dry eye going into going into that space right now. I'll tell you, the one other recommendation that I always give patients. There's a fair amount of evidence that, if you're getting too much of some of these preservative chemicals, which, of course, if you're going to use an eye drop bottle for a month, it should have a preservative in it, right? So that, you know, open the bottle and then it grows bacteria, a couple weeks later. Now, you're you're, you know, you're using contaminated eye drops. So,
Bottles. It's typical to have preservatives, but I really recommend for patients, if they're using anything more than a couple drops here. And there, further dry eye control to actually go for one of the preservative free artificial tears. They come in lots of Brands. I'm sure the house brands at any of the pharmacies, use them to make them too. And these are the ones that come in, like, strips plastic strips and you break one off, you break off the little cap. You could use a much as you want all day. You have to throw that one.
One out. If you have anything left over after throw it out, at the end of the night. And the next day break off a new one, because there's no preservatives. And once you open it, you don't want bacteria to grow in that salt water, right? But it's really good because the preservatives can be very irritating or even inflammatory to the ocular surface to the surface of our eyes. So we really do want to if we're using more than a dropper to upgrade the cost a little bit more money. They're still over-the-counter upgrade yourself to the preservative.
Three artificial,
tears. Those are great recommendations. I'm also really interested in this serum thing because, you know, where this discussion taking place 10 years ago and I raise PRP, platelet rich plasma, they were probably be a lot of eye rolls, no pun intended, because I think myself and a lot of other people in the, it's called a sort of standard scientific and medical community. Looked at platelet-rich plasma right alongside stem cell therapies because they were cheek to jowl back then as
You recall before the FDA regulations about stem cell claims, which we will get to of course PRP was suggested as a source of stem cells. It turns out there are very few if any true stem cells in PRP and yet now, as I understand it PRP is an FDA approved protocol for injection into the uterus, injection into pretty much every tissue and organ system of the body in order to quote unquote rejuvenated. And here I'm not promoting PR
And yet it is a very common practice. Now in more standard medical clinics but it started off kind of Niche even gray Market kind of underground. It's diverged from stem cell therapies and we're going to talk about major modes of vision loss in a moment and this horrible situation that happened down in Florida of a clinic injecting stem cells into patients, eyes to recover vision and it actually blinded them. So we'll talk about stem cell therapies. But for the record is PRP something that's now standard in major.
Optimal ophthalmic clinics, excuse me, including your department at Stanford, are you? You drawing out blood spinning it down taking plasma, taking serum and re-injecting it or reapplying it to patients, sighs, not yet,
in Ophthalmology. And I clinics, I would say we're sort of like, right now on the edge of groups are starting to study that. Is it safe? Is it valuable? Is it any better for certain conditions like on the ocular surface than serum tears?
Sample. This sort of diluting, a patient's own blood serum so so it's being studied, it's a very active area. Note turns out that this PRP plasma has, you know, again, like a high concentration of growth factors, that's probably what's responsible for a lot of the kind of quote issue Rejuvenation effects be that be, though, as they may, but, but it's being studied, but it's definitely not a standard of care yet. At least,
Least in, in Ophthalmology space. And and, you know, I think whenever there's something really new, it really deserves to be properly studied we talked before about, you know, at first you're going to do trials, where you just test it carefully in a few people, maybe a few of the most severely effective affected patients. Be really thoughtful about, you know, the ethics of trying out for safety, then, as you develop, a little understanding of the safety, you really want to eventually get to properly, controlled randomized.
What people in the community often called double-blind trials. But we in Ophthalmology like to call Double masked.
Trials. Blind is a bad word and often old you
blind trials. Yeah, so you really want properly controlled trials testing. Is it really working? Is it really deserve the claims that people are making and that has not yet really come to fruition at that level for Ophthalmology or I carry yet.
So we've been talking a lot about normal visual development. I checks
And some of the more typical challenges that people have with their Vision, but we haven't yet touched on some of the really debilitating stuff. Things like glaucoma things, like retinitis, Pigmentosa macular degeneration, the things that if we could, we would all avoid. And yet are out there in the world at pretty high rates. You know, I'm sure you'll share with us what those rates are and as bad as these things are, there are ways to detect.
And offset their progression so that people don't necessarily lose their Vision. So, if you could, could you share with us? What are the major forms of vision loss in childhood and in adulthood, and what can each and all of us do in order to find out if we have one of these conditions and therefore treat it
effectively? Yeah, that's great. You know, let's start by just reminding ourselves what are the major causes of vision loss and these are going to
If Ur where you are in the world but the major, the number one cause of low vision is actually refractive error, people who need glasses and especially in other countries, affordability access can't even get glasses. Okay? So that's just refractive error, but that's fundamentally correctable. The next most common cause of vision. Loss is cataract. Cataract is the blurring, the Aging.
The lens inside the eye, behind the cornea. We talked about how that is responsible for focusing light under the back of the. I'd also has to be clear enough that the light gets through the lens and cataract is a normal aging process, you know, as I said if we all live to 100 or 110 years old, we'll all get cataracts while all need cataract surgery. We actually as you know in the eye clinic we see cataracts years or even decades before they're affecting your vision in a meaningful way. So that the
The cataracts are forming and that's okay but at some point they get bad enough that it's time to take them out. We've actually solved for cataract surgery pretty efficiently we can do a four to eight minute surgery, maybe. If we're taking her time, it's 10 or 12 minutes of surgical time. Take out a cataract, it works beautifully, 99 point, something percent of the time we put a plastic, a clear plastic lens inside the eye. Exactly where your
Used to be and there's even lenses that can flax or focus light from far and near so Carriage is fundamentally a. There's still room for improvement but there's it's fundamentally a solved problem. The problem is that worldwide, there aren't enough cataract surgeons? There's not access to care the Machinery or the lenses cost. Too much money in, developing countries to get out to the number of people who would
Would need them. So it's actually just, again, an access to care cataract is a reversible, treatable easily, treatable problem. But it's number two on the list of causes of vision loss in the world because we don't have enough access to care. We need a lot more sort of programming around Global Ophthalmology Global I care to solve for cataract, just to bring that solution to countries around the world.
Then after that, you start hitting the eye diseases that lead to what are currently irreversible. Non reversible causes of vision loss. The number one cause of irreversible vision loss in the world is glaucoma. So what is glaucoma? Glaucoma is actually probably a little cluster or constellation of diseases that we lumped together. It's a degenerative disease like a neurodegenerative.
Should we talk about nerd to Generations in the brain like Alzheimer's and Parkinson's? Glaucoma is a neurodegenerative disease. It happens instead of affecting one or different area in your brain. It happens to affect the optic nerve that connects the eye to the brain. And we need our optic nerves. Carry, all the visual information from the eye to the brain. And so, if your optic nerve is degenerating in glaucoma and I should add their other optic neuropathy, these so-called diseases of optic nerve degeneration,
Ocean, for example, you can get a stroke of the optic nerve. You can have an inflammatory disease, like multiple sclerosis, called optic neuritis, that affects the optic nerve, so you can get other optic nerve diseases. But glaucoma is by far the most, common optic neuropathy. And the problem is, is just like, you know, just like spinal cord injury, which is also part of the central nervous system, right? The brain, the spinal cord, the retina, the optic nerve. That's the central nervous system, and there's no regeneration and that's why
I don't cord injury leads to permanent paralysis, while optic nerve injury or optic nerve degeneration. Unfortunately, leads to permanent vision loss. So in the case of glaucoma, how do we get ahead of that? Glaucoma has two major risk factors. One is increasing age. There are actually infantile and pediatric glaucoma's unfortunately and those can be much more aggressive much more damaging when they present so early and kids in babies
And in children, most of the kind of run-of-the-mill, glaucoma usually presents presents in adulthood and even in the Aging adult so much more. Common after 50 or 60 or 70 years old, increasing the other main risk factor for glaucoma is increasing. I pressure the I actually you know, it stays inflated, it's a balloon. It has to stay inflated. We need some amount of eye pressure to keep our eye as a, as an inflated balloon, but if the eye pressure goes too high and we
Talk about this before. You won't even feel it. If it slowly gets too high. If the eye pressure goes too high, that causes glaucoma. And and that's one of the things that we talked about. You really include in a comprehensive eye exam, when you're just getting a screening, check up at your eye care provider at your optometrist or ophthalmologist office, they're going to check your pressure and just as a screening tool check to make sure it's not too high.
We can treat glaucoma today by trying to reduce the impact of that high pressure by lowering the eye pressure. So we have treatments for glaucoma that Target. The eye pressure, we have medications like eye drops. We have lasers that can be used inside the eye that can also lower the eye pressure. And ultimately, if we need them we also have surgeries that can also provide an outflow that lets the fluid out of the eye in a controlled way. So that the
High pressure can be brought back down into normal ranges again. The reason that glaucoma
Ends up being the number one cause of irreversible blindness in the world is number one. We can't get those therapies everywhere in the world. The affordability of eye drops, the access to lasers or surgical procedures around the world is an equal to what it is here and even within our country. You know, people may not be accessing Healthcare effectively, to get screened for glaucoma or to get treated for glaucoma. The other big problem with glaucoma is
Is that it affects our peripheral vision first and only very late in the disease, does it pinch in and finally pinch off the center of our vision in typical glaucoma's. And that's a real problem. Because we don't notice if our peripheral vision is down in our peripheral vision. Isn't that good to begin with? And if you're driving and you can see a pedestrian step off the sidewalk. You think your peripheral vision is fine but actually your
Peripheral vision could already start being damaged by glaucoma and you won't notice it in regular daily life. And that's where the importance of screening and early detection. Really comes in for glaucoma, what we don't have for glaucoma. We can come back to like kind of what's The Cutting Edge or the future in these eye diseases. What we don't have are treatments that really Target the optic nerve degenerative process and we can come back and talk about that. So that's
glaucoma and optic neuropathies. Then the next two major causes of currently largely irreversible vision loss are age-related macular degeneration.
And then diabetic retinopathy now age-related macular. Degeneration is just like, it sounds major risk factor is age, it's very common and actually in the developed world, you know, countries that are more developed also countries that have a larger Caucasian white population. Its more common in certain populations than others. It actually is, you know, definitely a leading cause of vision loss in the elderly population for example.
United States and there's two forms of macular degeneration, but they both end up targeting the same part. The same part of the retina and the part of the retina, is really like the rods. And the cones that we talked about before the rods. Do your low-light Vision at night time primarily your cones do color vision and bright light, you know, sort of normal lighting that we experience it, you know, through most of our awake die.
And in that back of the retina, you can have what's called dry macular degeneration, which is a slow thankfully slow, but slow Insidious disease. That causes the degeneration of the rods and cones. And also, the support cells that help feed the rods and cones and take care of the rods and cones. They're called rpe cells and retinal pigment epithelium. It's not really critical. Of course, the names of every different cell type, but these are like the
Light collecting cells in our eyes in the rat, and they degenerate and macular degeneration, and in the dry form, there's the slow degeneration, but some percent of people with the dry form of macular degeneration, will actually convert to What's called the wet form. That's called wet because new blood vessels actually grow in appropriately under and even into the retina and new blood vessels. Unlike our mature, blood vessels tend to be leaky and so,
The fluid leaks, out of those blood vessels gets into the ratna interferes with vision and that can lead to a much more acute loss of vision. Now, we have some treatments for wet macular degeneration. We have injections that going can go into the eye that actually fight against the molecules that are causing those new blood vessels to grow. These are antibodies that can be injected in the eye and they can be very effective, controlling patients, wet macular degeneration.
Ian, it's been a much bigger uphill battle. Even of the last decade of his, as advances are being made. To really try to knock back order or slow down. Even the dry form of macular degeneration. There is just an exciting news. Even just in the last few months, the first successful Trials of a treatment for the dry form. Have just shown success and properly, randomized controlled human clinical.
Trials, phase 3, clinical trials, so it's an exciting time. Those new treatments are not going to be a Panacea, they slow the progression. Like the an anatomic progression of the disease, Maybe by 20 or 25%. So patients are still going to get worse even with those treatments or there's still a lot more to be done to really knock back macular degeneration. I want to mention you mentioned, retinitis Pigmentosa that's like an animal
Herod form of a type of macular degeneration. It's also affecting the rods and cones, and also the support cells. The rpe cells, in the back of the eye retinitis, Pigmentosa is an inherited form. There are actually many different genes you could have that. Could leave two retinas pigment. Pigmentosa in aggregate, if you add up all the people with all those different genes and it can be very devastating because it can really affect the vision.
And knock out your vision very early in life, including in children and even former versions of that and babies, but you add that all up. It's still much less common in aggregate the macular degeneration, but in a way it's, you know, quite a bit more severe because it does affect people much earlier in life. So so I sort of clumped those together, macular, degeneration, retinitis Pigmentosa degeneration of the rods and cones and the support cells, the rpe support cells and then you can't have this
In the discussion about water, the devastating eye diseases without bringing up diabetic retinopathy, especially, because diabetes, unfortunately, really continues to grow in, especially, what's a in. The United States are only in the developed world, you know, as we especially type 2 diabetes with eating habits exercise habits contributing to a proliferation of some of the risk factors for type 2 diabetes. Metabolic syndrome of be
City where unfortunately seeing a proliferation a growth in the number of people with diabetes and with the growth and diabetes, unfortunately comes a growth of the complications of diabetes and one of the major complications of diabetes is damage to the retina inside the eye and we call that diabetic retinopathy and there again, some of the same damage that occurs especially when in diabetes. Again, some new blood,
Cells are growing or blood vessels are leaky. Some of that can be treated with used to be lasers. And now more commonly is often being treated with some of the same injectable drugs that are treating macular degeneration. But there's still a lot of vision loss with diabetes and diabetic. Retinopathy, I think that's an area where again early screening making sure if you have diabetes, that's, that's an indication where you definitely have to be going in and getting
At least annual exam with an eye care provider or having someone take a photograph of the inside of your eye and rate that photograph to say. If you have any diabetic retinopathy or not, in terms of interventions, can we
talk about diabetic retinopathy first? Because course type 1. Diabetes is a failure to produce insulin relatively rare compared to type 2 diabetes, which as you mentioned is proliferating in developing countries, right? This is probably
And in the sense that developing countries have better Medical Care typically than undeveloped countries more opportunities for food nourishment and yet, it's clearly a problem of over nourishment. Insulin insensitivity. Obesity Etc. Is this type of diabetic retinopathy that one observes the same for type 1 diabetics versus type 2 diabetics because my understanding is that type 2 diabetes, this insulin insensitivity
Is a bit of a Continuum, right? I mean the type 1 diabetes is, as far as I know is all or none. You either make insulin or you don't type 2 diabetes. Someone could be mildly in insulin insensitive or severely insulin insensitive and sometimes I'm told people are not necessarily obese and can have type 2 diabetes as well. Certainly things like smoking and alcohol intake can contribute to that. So how equivalent are type 1 and type 2 diabetes when
Framed Under the Umbrella of diabetic. Retinopathy?
Yeah, the the time to presentation can be different. A type 1 diabetic, usually presents with sort of a cataclysmic sudden loss sudden sort of final loss of their ability to make insulin. It usually presents in childhood or teenage years but can present you can have late onset type 1 diabetes because it's kind of a sudden presentation
It can take some years after that to show any diabetic retinopathy whereas just because just just like you said type 2 diabetes can be on a Continuum people can have like kind of a mild type 2 diabetes but kind of be you know, getting along, you know, going through life kind of maybe not even realizing you know at first and so when you're diagnosed with type 2 diabetes you've probably had some insulin resistance for the years prior to your diagnosis.
And so, in that case, you often can have, you know, like you're at higher risk for presenting sooner with the complications of diabetes, like, diabetic retinopathy. Now, given that the actual retinopathy is very similar. May be the same between type 1, diabetes, and type 2 diabetes. And again, it involves things like leaky blood vessels. New blood vessel growth. There's some amount of neurodegenerative dysfunction that.
Simply occurs so you can have little little hemorrhages or bleeding spots in the retina tiny little strokes or micro vascular events in the retina so that can happen in either type 1 or type 2 diabetes. Once you start having the retinopathy it does look pretty similar.
So what can people do to prevent or treat diabetic? Retinopathy obviously, the type 1 diabetic needs to take insulin in order to survive, really
Type 2 diabetics need to get their obesity under control if they are, in fact, obese and get their blood sugar levels under control regardless, that's my understanding. And by extension, are you seeing any reductions in diabetic, retinopathy with people that are taking these glucagon-like peptide, mimics like goes em pick which is used to treat. Type 2 diabetes.
Yeah. It's been a very exciting development for the diabetes field. This new class of
Of of anti-diabetic drugs. And so there you've touched on a couple of them. There are a few key things for reducing the risk of diabetes, or the impact of a diabetes, on your retina risk of diabetic, retinopathy or impact of diabetes on your retina. One is, as I mentioned, get regular eye exams, be screened. You know, any diabetic should be screened at least once a year.
With a good comprehensive retinal exam, looking for any of these items. The number one most important element to prevent diabetic retinopathy is to control your diabetes and having a real good blood sugar control. Keeping your hemoglobin A1c which is one of the blood test that gets used to measure how your kind of long term diabetes management is going. That's really, you know, first and foremost the
Most important and that's been shown in large, clinical trials, they actually randomize patients to hey take care of your diabetes or do our real, good job taking care of your diabetes and the patients who did a real good job taking care of their diabetes have much less diabetic retinopathy, so that's number one. It turns out that if you have high blood pressure and diabetes, that blood pressure is also really damaging to your retina. Also, by the way,
the kidneys and probably all the other organs that are suffering from the diabetic insult. So in addition to controlling blood sugar really important to have blood pressure under great control, now, both blood sugar and blood pressure in type 2 diabetics, especially if you're catching them early can be improved with some of these, you know, so-called Lifestyle Changes like improving eating watching what your food intake is you know getting good exercise trying to lose weight.
So these are definitely on that list of how do you get to good blood sugar and blood pressure control but suffice it to say blood sugar and blood pressure control right at the top. And then also, including the regular at least annual exams and then if diabetic, retinopathy is detected and blood sugar blood pressure control are not going to be enough for that patient. We do have treatments as I mentioned before their drugs that can be injected if
Your retina is getting, you know, kind of leaky blood vessels from diabetes. There are treatments that we can give the, I specifically to try to counter the diabetic.
Retinopathy, terrific, in terms of glaucoma, as you mentioned, glaucoma is related to pressure, although there is pressure normal, glaucoma glaucoma is a death of the retinal ganglion cells, the neurons that connect the eye to the brain, and once they are gone,
To this point in human history, they can't be replaced. Although hopefully because of work that you've done and that other Laboratories are doing at some point that statement, I just made will not be true and there are GCS can be replaced.
Meanwhile,
what can and should people do to find out if they have glaucoma and to treat glaucoma and is it true that even if somebody has normal pressure that lowering their eye pressure further, protects them against
glaucoma.
Oh yeah, that's absolutely right. So most important is to get screened with a formal exam at your optometrist or ophthalmologist because you, you won't notice, you won't have any symptoms. If your eye pressure is too high. You won't know you're not likely to notice until very late in the disease. If your peripheral vision is being damaged through the course of glaucoma. So most important as having a screening exam, a good comprehensive, screening exam will always include checking the
Pressures. And also looking in the back of your eye, the head of the optic nerve were all the fibers, leave the eye and carry the optic nerve information. Back to the brain, we can see that when we look inside your eye, and, and glaucoma has a fairly characteristic look to it in the optic nerve head. So so looking at the optic nerve had, we have Imaging and peripheral vision testing that can also be included in those screening exams. So if you really get a
Pensive screening exam, you can very reliably detect if you have glaucoma to worry about or you're in the clear. If you have glaucoma to worry about, we have treatments and you're absolutely right. Whether you start with a abnormally high pressure or you start with a pressure, that's on the face of it. In the normal range, in either case lowering, the pressure has been shown in large properly, controlled clinical trials to slow the progression of optic nerve damage.
And vision loss. So absolutely. In either case, starting with high pressure or starting with normal pressure. In either case, you've got a lower the pressure further. And as I mentioned, we have eyedrops. Those are usually the first line. There's very good data that there's a very benign non-invasive laser, it's not the same kind of laser that gets used for Lasik, but there's a benign very safe type of laser called selective, laser trabeculoplasty SLT. We call it and
Also very effective as a first-line actually in the largest clinical trial from which the data have been coming out just even over the last few years, it's called the light trial in the light trial patients. With glaucoma were randomly assigned to either get the laser or the sort of most common first strongest I drop. And that gets used clinically and actually on many features. They both worked at least as well, but when looking out over the long term,
With the laser had some advantages over the eye drop, not in the least of which, by the way, it's very nice for patients. Do not have to, like, remember to use the eye drop every night and so, so that's quite helpful. I think, to keep in mind as a treatment option early in the course of the disease, of course, if the eye drops under lasers are not enough early in the disease, we also have surgical approaches to lower, the eye pressure further, you know, even with all of our treatments, all of these treatments,
tapping patients through all of this about 10, 15. Even 20 percent of patients will lose very meaningful, functional vision and maybe five, ten fifteen percent of patients especially depending where you are in the world will go blind from glaucoma including in, you know, quote-unquote developed countries. There's still a very significant cohort of patients that go blind legally blind. And then, you know,
Blindness like can't even tell if the lights are on in the room. So it's devastating, it's Insidious. It's hard to detect early and socolow coma, still a tough one, even with all of the treatments that we have,
okay. So get your pressures checked folks and if you are prescribed drops, take your drops. I hear about patients not taking their drops which to me just seems like baffling but I guess having to do
nothing day in and day out is can be Troublesome enough that unless people are losing their Vision very quickly or they are very afraid of losing their Vision. Sometimes they just neglect to take them.
It's hard. It's hard for glaucoma eye drops. It's hard for taking your blood pressure medication. It's hard for a lot of medicines. You know, if you're, if you're taking a medicine, where you don't feel better, you know, if you have a headache and you take an aspirin or Tylenol or Ibuprofen, you know, you feel better, you feel reinforced gosh, taking that pill made sense, right? But if
Using an eye drop that like, hey, this is going to protect you for the next 20 years from losing your vision, but you don't notice every day that anything's better, and by the way, the eye drops could be a little irritating, maybe it stings. A little for a minute or two, when you put it in your eye, some people are even less tolerant of the eye drops. It's hard to feel motivated every day, and we know that we call that compliance. We know that it's very hard for patients to stay compliant with prescribed medications, where they don't feel or notice a
Rinse in a daily
way.
I realized that we can't stop aging yet but right now you can't stop aging. An age is a risk factor for glaucoma. My understanding is so is smoking or vaping nicotine and so is alcohol and by that reasoning should people strive to drink less and smoke less, including vaping nicotine less if they are concerned about
glaucoma. Yeah, I'm not just glaucoma macular.
Generation actually macular degeneration as a couple, major risk factors macular degeneration aging just like with glaucoma major risk factor smoking including exposure to secondhand, smoke major risk factor for macular degeneration, and for the progression and vision loss potentially associated with macular degeneration, in the case of macular degeneration. There's also a couple of genes that we've sequenced the human genome, and there's a couple of genes associated with macular degeneration to, that's
Less true for your typical run-of-the-mill. Adult clout Kuma. There are genes for the Pediatric and infantile forms of glaucoma. So, yeah, smoking 100%, including vaping. It's a No-No for your eyes. Just like it's a No-No for the rest of your body and it's tough as the eye doctor to have these conversations with patients. Because you kind of feel like, well, you know, they must know it already and I'm trying to be the good guy in the room with the patient. Convince them to use their other medications but
It's important for us. Also, as I care providers to reinforce the message with her patients, a smoking, terrible idea for macular degeneration. Also for glaucoma, you know, glaucoma is interesting because the optic nerve where it degenerates kind of right at the head of the optic nerve where it where it exits the eye, it's what we call a watershed Zone. It's kind of a edge of to blood vessels supplies, and if either of those blood vessels supplies are a little bit short, on bling,
Blood or oxygen supply to that optic nerve head. Your glaucoma is going to get worse, your optic nerves going to be underfed and that's going to worsen this degenerative process just by not having all the right nutrients and oxygen. So the other thing is that especially for glaucoma everything that we talked about for being heart healthy
For the rest of our body is is almost certainly true for glaucoma. And so I also always counsel glaucoma patients, it's not just no smoking but eat healthy, have a multivitamin, get some exercise, all those things that are good for your cardiovascular system. Are going to be good for your eyes in general. And in particular, if you have glaucoma or risk high risk for glaucoma, I realized that smoking or vaping are problematic for glaucoma and
For macular degeneration but we can't have a conversation about glaucoma without at least mentioning cannabis. I did an entire episode about cannabis which touched on some of the real dangers of very high THC concentration. Cannabis this lost me a few followers, I'm sure no problem because what was important was to convey the fact that the Cannabis that's out there, nowadays comes in a variety of different strains and ratios of THC to CBD. There's some severe risks of
High THC especially in young males, although not always the point. Being that there are, I want to be very clear about this because for whatever reason cannabis gets people really up in arms, they always say it's not as bad as alcohol but guess what? We did an entire episode about alcohol and there the message is very clear 0 is better than any and to a week is probably the limit and if you're an alcoholic 0 is the rule. So
With cannabis, it's clear by my read of the data that it can lower eye pressure which may undermine the progression of glaucoma somewhat. But if people are smoking that cannabis is it therefore going to offset any gain that one would get from that cannabis and then how does one account for the potentially problematic aspects of very high THC cannabis? Yeah it's a great question. And the truth is that in most patients cannabis will lower the eye pressure.
The problem is, is it really only lowers that I pressure During the period that you're high from the Cannabis? And the second problem is that smoking version of getting that cannabis into your system. The smoking is bad for your lungs. By the way, the smoke from Cannabis or from cigarettes is also terrible for your dry eyes. It causes inflammation. It dries out your eyes it. So it's also very bad from that perspective now. So,
The problem with cannabis is not that it doesn't work to lower the part, we want to lower the pressure, that's great. The problem with cannabis is that it's not realistic for most of our patients to prescribe. Could you go out and be high from Cannabis 24 hours a day? 7 days, a week for the next
20 years? I'm sure some people have tried and succeeded but right that's not practical for most people and certainly for young people it could be really especially problematic I should say
absolutely so so I recommend not
That approach. But that said, I am definitely not a decry or of it and now that there are edible forms, I certainly have patients who are using it in a responsible way, especially edible forms and and in select cases like that, could make the difference for them helping to keep the pressure down. And I'll say, for example, it turns out you've talked a lot over the last couple of years about diurnal curves and circadian rhythms. It turns out that our eye pressure off
Also undergoes a circadian rhythm and it's actually highest at night while we're sleeping kind of peaks in those early morning hours, then hits a low throughout the early day and then kind of rises again throughout the afternoon into the evening. And we have a lot of patients who they come in to their Clinic, visit their eye pressure looks normal, but it's actually quite a bit higher when they're at home and that could explain some fraction of what we call normal pressure. Glaucoma. It just looks normal. During the day, it's actually high at night. And so, in particular some patients, I certainly
Some patients who are using these products like let's say before bad and if it's controlling their eye pressure at night while they're asleep. When the eye pressure would have been the highest it may confer some protective advantage over time, but that's that again like for most patients, it's not going to be the primary approach. I'm most excited about the idea of, you know, Laboratories or companies, figuring out which the compounds Within These cannabinoids there.
R called within these products are actually responsible for lowering the eye pressure. And can we get like, a more potent? I specific long-acting drug. That's basically derived from the concept of cannabis but works better and is more compatible with not bringing along all the other, adverse elements that can come with cannabis. Use
you mentioned the Circadian rhythm and I pressure and the fact that I pressure is higher at night.
Is there any advantage to sleeping in a particular position? I know this might sound a little detail, but I seem to recall an abstract or a paper a few years ago at a meeting that you and I both attended what that said that if people slept with their head below their feet, I pressures were higher than if their head was slightly elevated above their feet. And for somebody who has glaucoma, this could make pretty substantial difference in terms of their eye pressures at precisely the hours of the night we should say in which they could be doing the most damage to the ganglion
cells. Yeah.
Absolutely. And we will sometimes counsel patients with severe glaucoma, especially if they're, you know, poorly responsive to standard therapies or poorly able to tolerate standard therapies will counsel them. If they're able to sleep up on a couple pillows, get kind of a 30-degree sleep angle going. What I don't want to do is interfere with a person's sleep because I just, I fundamentally feel for the total health of the whole human being getting a good night's sleep is
Maybe more important than that, 30 degrees. And if trying to sleep up on pillows, at 30 degrees is going to lead to kind of restless difficult sleep night. I'd rather the patient, get a good night's sleep, but if they can tolerate it, and especially if they have a sort of a tough version of glaucoma then, well, let them try. See if they can sleep up. The other really interesting question that arises is does which side you sleep on effect, which I might have worse. Glaucoma. Glaucoma is
Is almost always with, with a few rare exceptions, almost always a disease of two eyes but it can present very asymmetrical. In fact, it's quite common to have one, I kind of have worse damage than the other and we don't know fundamentally. Why? That is but one hypothesis was gosh. Maybe if you sleep on the right eye, then you're right. I will have worst of Oklahoma because the pressure is a little higher down below or maybe it's pressing on the pillow in a way or something like that. There have been a couple studies.
Really, really looking at that question. A couple Studies have said the lower. I'll have worst glaucoma couple Studies have said the higher, I will have worse glaucoma. So the upshot is a probably doesn't matter which side you sleep on. We also know when you video people in their normal sleep pattern. Even if you feel, you always fall asleep, on the left side of your face, people toss and turn all night. Probably over the course of the night. You're spending a similar amount of time on each. I
glad you brought up that point in terms of
Euler degeneration, I'm curious about the things that people can do as opposed to the don'ts in order to perhaps offset macular degeneration. One of the things that I'm intrigued by are the results of Glenn Jeffrey's laboratory over at University College. London, I had known Jeff for probably a decade or more and he typically worked on animal models. But then a few years ago, started publishing studies and I believe there are now two published studies showing how red light exposure and near-infrared light exposure done.
Early in the day to the eye at a distance of about two feet for just a couple of minutes, a few times a week could offset some of the vision loss associated with age-related macular degeneration in people older than 40. That's my understanding of these studies and there's a theory there about enhancing function of mitochondria and photoreceptors by reducing reactive oxygen species. There's a whole mechanistic hypothesis. But my question is is that the sort of protocol that produces significant enough
Offset of macular degeneration. Like we should all be looking at red lights in the morning. Or is it still too early days in order to really conclude that? All
right, I think the data is very compelling, the data are valid very compelling that this kind of red or near infrared, light therapy can be at some level neuroprotective and yes the data suggests that kind of ramping up. I high-functioning mitochondria as a part of
At activating neuroprotective Pathways in the retina. It's actually been demonstrated in animal models and a little human data here and there but both for macular degeneration kind of degenerative disease but also for optic neuropathies. You know like glaucoma and retinal ganglion cells, the cells that carry all that visual information from the eye to the brain. There are chock-full of mitochondria to. And and so the idea that this could be a therapeutic approach. I think it's very compelling.
There are a number of studies actually I think still ongoing today really trying to figure out what's the right dose. How much brightness do you need? Is there an optimal wavelength? How many minutes does it matter? When during the day? You provide, that light or how many minutes or hours? These are still very much open questions. You know, what's the dose, what's the delivery? But it's, it's it's very promising looking, and there's biological premise and
I'm excited to see where that goes because again that's like a that's a very accessible sort of therapeutic approach. That could be brought to a very broad swath of people. So I'm excited about that.
Sorry, I didn't mean to drop and completely non-invasive. I should probably mention a warning which is if people are going to decide that they're going to jump on this result and do red light exposure in the early part of the day. No matter what color a light is, if it's too bright, you can damage your eye.
Why? So the I think this is why you're pointing the fact that we need established, protocols it. Before people really start blasting their eyes with red light. And if they are going to expose themselves to Red Light, it shouldn't be uncomfortably bright. Do I have that? That's
absolutely right. You know, actually light effect, we talked about this a little bit earlier. There's actually now data also that red light and actually interestingly studies using light at the other end of the visible spectrum, violet light either of those in
Small. Daily doses can also be used to prevent progression of nearsightedness in children in school age children. And so, I think we're really just on the cusp of really understanding the biology of how these different light therapies might be leveraged maximally to, to maximize our Eye Health and both during development and at the other end of the spectrum as we age. So it's an exciting area, and I think this kind of photo therapy
She is, you know, a very hot topic for research right now, very hot
topic. One has to wonder whether or not these light therapies. The fact that infrared works and maybe ultraviolet works is, are really just capturing some of what sunlight is naturally doing when as you mentioned before a child or perhaps an adult. Also spends a certain number of hours outdoors. I mean maybe we're just filling in the blanks that are neglected nowadays, because we're spending so much time. Indoors under artificial lights and in front of screens. Yeah. Yeah.
Yeah, very thoughtful possibility of
have a couple of, we don't have to call them quick questions, but common questions that perhaps have brief explanations. For instance, I put out a request for questions in anticipation of this episode and I got a lot of people asking what are floaters in the eye and is there anything that people can do to get rid of floaters?
Yeah, RI when we're born, is actually filled in the middle of it with a
Jelly, it's not just flew and it's kind of a jelly. There's collagen fibers and thankfully, the whole jelly is largely invisible. So the white can get through our eye back to the retina without being impeded as we age, those different fibers, and gels, shrink and contract, and they peel off of the back of the retina. So, there's just in the middle now. Your eyeball doesn't shrink because it fills in, with, with fluid, with salt water, basically,
The gel perch ranks and as it shrinks and also pulls peels off the ratna. It can pull off kind of little tiny retinal B, not important to your vision B, but just like little tissue bits. And also, as it congeals, it kind of can get little concretions in the jelly and we perceive those as floaters. You know, little almost semi-translucent or in some cases kind of grayish blackish sometimes, sometimes you get a big one, if it peels off the edge of the object.
Nick nerve in the back of the eye as happens. We call that a posterior vitreous detachment. You can actually see like a moon or a half moon, floater in Your Vision. These are very frustrating to a lot of people and the good news is in almost all cases, they will just go away by themselves in theory. It's been played with gosh we could do like a big surgery to chew up all that jelly replace it all with saltwater try to get rid of your.
Hers. There's risk associated with that surgery. We use it very effectively in retinal detachments or other diseases, bad diabetic, retinopathy bleeding. Inside the eye, we can take out the jelly from the I replace it with with, with salt water. But that's not, you know, putting patients through the risk of that surgery just to get rid of a couple of floaters or few floaters that probably are going to go away over the next few months. I actually like to tell patients
Nothing to worry about just ignore them. And actually if you stop focusing on them, your brain will actually start filtering them out. You'll stop noticing them if you can kind of not worried about them, be a little intentional about ignoring them in the beginning, and then they do actually go away. And look some will go away. These three will go away. These two will appear eventually. You'll stop having floaters most patients will stop having floaters, so we really don't like to put a patient.
At risk by intervening. We really liked. In this case just reassure them, it's going to be okay. Just ignore them. They'll eventually go away.
Thank you for that answer. Twitching of the eye is something that people complain about. I know when I get tired, I'll get at which over one eye. I think there's a condition is it called myasthenia gravis where people go through a stressful, period or get very fatigued. And I think that's a depletion of the nerve terminal communication between the nerves that control. The
Muscles of the eye. And then people get this kind of, like, hooded eye. Look where they have a hard time opening their eyes, but barring something extreme like myasthenia gravis or staying up for two days working or even just being a bit sleep-deprived. What causes the twitching of the eyelid and is there anything people can do about
that? Most of the time? It's actually just a bad nerve ending, you know. Maybe that one nerve cell, you know your eyelid is fed by you know, hundreds, maybe it's thousands.
Of nerve cells that are doing the muscles. They're doing the feeling, obviously, the ones controlling the muscles that can lead to a twitch, if one of those nerve cells kind of just starts, you know, maybe that one nerve cell is dying. Just, you know, whatever the age you can process, you know. It happens in young people to though. So you got one bad fiber. That's just deciding to kind of ring off the hook. That's that's that telephones. Just ringing off the hook and it's just activating the muscle. So you're just twitching that muscle.
I've had them as well and you can have not just in your eyelids. You can have this anywhere in your body, like one little spot on your leg. We're just the muscle, right? Under the skin is just and typically, it will happen over the course of a couple of months, intermittently some days more sometimes, last maybe a correlates with when you're tired a little bit sometimes and then it'll stop that nerve cell will either reconnect properly and stop doing that. Maybe it dies. We don't really know.
But typically it lasts on that scale. Now, there are other diseases, not just myasthenia gravis, you can have blepharospasm, like, where you have a chronic spasming of certain nerves causing muscles to spasm. And there we can use we can use treatments. For example Botox is a treatment that you know people use for cosmetic reducing of wrinkles for example, but you know a really good medical use of Botox is preventing that blepharospasm.
I'm and patients can come in once every three or six months, if they have a really severe spasming version of what you're describing. But the regular occasional run-of-the-mill last a couple months, nothing to worry about, it does not proceed anything bad happening in your future and maybe let it run its course. And you'll be okay.
Great.
We've all heard that carrots are good for our vision which presumably stems from some peripheral understanding about the fact that vitamin A is integral to the photosynthesis pathway of converting light into electrical and chemical signals that the rest of the eye and brain can use. And yet I'm guessing that there probably aren't that many people walking around, who are vitamin A deficient, they're probably out there but not that many, especially in developed countries.
And in addition in the last really five years, but in particular, in the last two years, I've seen a proliferation of supplements on the market to promote I Health and Longevity of vision. I'd love your thought on this General theme of nutrition and supplements for improving Eye Health, or for maintaining Eye Health. And before we started recording, you mentioned that Ophthalmology? Or at least I health is one area of medicine that has
As a bit not extensive but a bit of a longer history of exploring supplementation in rigorous randomized, controlled trials, where as other areas of Neuroscience and Neural Health such as Alzheimer's Etc. Certainly there are brain health supplements out there but there aren't a lot of rigorous data to support them just yet. So what are your thoughts on nutrition aside from the standard thing of you know, people shouldn't be ingesting too many calories, such that they are obese and diabetic and therefore you know etcetera.
Act effects of nutrition. What are your thoughts on nutrition and supplementation for
Eye Health? Yeah you know you're absolutely right and again in Ophthalmology we actually do have quite a bit of studies. There's been quite a bit of attention over the years. Even over the decades looking at this question and I think it's worth highlighting a couple of yeses and a couple of nose for macular degeneration, which we talked about being an exceedingly common, cause of vision loss. There have been two
The age-related eye disease, studies called, are Ed's age-related eye disease, studies are as there is Air Raids, and then errands to, and those studies were a large randomized. Trials of using giving giving patients supplements, and in arid, zit was vitamin c and e higher dose than would just come in a multivitamin, zinc and copper.
And then also beta carotene. And beta carotene is one of these what are called carotenoids. It's a if you look at the extended family, there's maybe 600 different chemical entities of these carotenoids and beta. Carotene is one of them that's in the direct pathway of making vitamin A and so that was the principle in the Arid study and the Arid study showed that patients randomized to these pills compared to controls it did. These are antioxidants and part, right? In addition to
Getting into that vitamin A pathway and and the patients randomized to get that supplement mixture, showed less progression of their dry macular, degeneration in the moderate, to severe ranges. If you had mild macular degeneration, they didn't show a statistically significant Improvement, but I will say it's my experience, you know, myself with patients and seeing how the field works, you know, if you have mild macular degeneration even though it's not as clinically proven, we're still off.
In recommending. Hey, if you can afford that supplement to go ahead and buy that now are AIDS, Was Then followed by a second study earrings, to also, with vitamin C, vitamin E, zinc, and copper. They actually tested whether a slightly lower dose, of zinc, would be as good as a higher dose. And a lower dose was as good as a higher dose, and then, instead of the beta-carotene they tested against the beta-carotene, they tried to other carotenoids that are called lutein and zeaxanthin. And
And they actually found had to had that the second, the Arabs to formula without the beta-carotene and with the lutein and zeaxanthin, that that formula was even better at slowing dry macular degeneration in the moderate to severe population again. It's not clear how much it may help mild macular degeneration, but in the sort of clinically defined moderate towards severe group, there was a statistically significant reduced up by about 20
25% the progression of your dry, macular degeneration. And you know over a couple of years twenty-five, five percent, you may not notice but over a couple of decades you know that could really slow down the progression of your disease. Now it turns out that the beta-carotene they noted, a little bit of an increased cancer risk in the patients in the Arabs, one who had that beta-carotene mostly in patients who are smokers. They also noticed in the second one that if you were already not
Being a multivitamin or not eating a diet, that's already naturally rich in lutein and zeaxanthin that the effect of that supplement was even stronger. So it was very strong clinical trial support for taking what we now use. This are words to supplementation and I'm sure we can list the formula or put it in the links under under under your podcast that that that's really does slow macular degeneration.
So that's like a very strong example of a. Yes you should do this. There's one. Yes. Brewing in the glaucoma field right now and that's high dose, vitamin B, 3 b. As in boy 3, it's also called in its various forms. Either nicotinic acid or nicotinamide, the nicotine sounds like nicotine but this is not a substitute for smoking or vaping this is a different. This is a vitamin that just has a very
Miller sounding name. It's in the nadp synthesis pathway. That's exactly right. It's in the NAD pathway. NAD is one of the oxidative stress regulators and energy Regulators of ourselves. So it's a very critical molecule in the metabolism of ourselves and there was very strong evidence in cleat preclinical models of mice. Given glaucoma that manipulating this pathway and, and sort of increasing. This pathway could be protective in glaucoma or other.
Optic neuropathies, optic, nerve degenerative diseases, and so there have now been to limited but randomized, controlled clinical trials, one. Looking at glaucoma patients looking at their visual field so they're actual visual performance and the other looking at the electrical signals in the I called in electroretinogram kind of like an EEG does for your brain. We can do an ERG for your retina and in both of those trials, high dose vitamin.
B3 was a found to be very safe and be was shown to actually improve at least in the short term improve rational function measured either on visual field testing or on the electroretinogram. Now, this is now entering clinical trials, large kind of phase, 3 style, clinical trials, actually around the world. It's a very hot topic for glaucoma. The fact that this NAD
Sting supplementation with high dose. Vitamin B3, might be a great approach to helping protect the nerve in in glaucoma. And so as I say, there's there's three or four, large randomized, phase 3 style clinical trials, starting now and so over the next year or two will get more data. But I'll tell you like, I have patience and if they're at the end of their rope and we are having a lot of trouble controlling their vision loss from
Now, coma. I'm already recommending in these limited cases. Hey, why don't you try this? It's almost certainly safe and it may and it may help and it may help protect your vision over time. So, so that's that's an area that's kind of another. Like, kind of could be a yes, early data is pointing in the right direction. You want to be careful but but I am starting to recommend it at the same time that we're actually doing the clinical trials. Now,
Now that said there are a lot of other things that people talk about other supplements, ginkgo biloba, things with generic names on the internet. Like you know glaucoma preservation. Oh yeah
yeah that's our thing makes my gives me hives, you know.
Yeah. And these are areas where there might be scientific premise like a plausible explanation for how this should help but not good data. That it actually helps thankfully in most cases these
You're safe, but I just worry about patients hitching, their wagon to something. That's not going to help them getting their hopes up. Ah, worst case scenario, not taking their actually proven prescribed treatments and instead using an alternative therapy that doesn't have data to support it. And so I think there there's a lot of you know, you know, either unfounded unsupported, you know, information at
Is around chatrooms travels around the internet, one person tells the next person, you know, there's inappropriate advertising for some of these and they're, you know, I really don't want patients to be hurt, not necessarily hurt by taking something that's not helping, but but may be hurt by feel like I don't have to go to the doctor. I'm taking the supplement and that would be, obviously a really bad potential outcome for a patient.
I completely agree. Supplements are just as the name suggests a supplement.
To an already, hopefully healthy lifestyle and use of medication where it's prescribed. And I've often said on the podcast that sometimes the best dose of a supplement is 0 mg. So I do appreciate you touching on those themes, because supplementation is something that comes up from time to time on the podcast. And I know that I've certainly have seen a number of these different eye and vision support supplements, we aren't affiliated with any of them. I don't personally. Take
Any of them but these
clinical trials sound promising. So I'm going to
keep an ear to the ground for them as a final question. And hopefully a topic that we can cover in more detail in a subsequent episode of the podcast. Because I absolutely want to have you back to discuss this in more detail? I'd like to just get your thoughts on the fact that the neural retina is in fact, neural and it's part of the brain and we are hearing an increasing amount of positive chatter about
The use of Imaging the eye, and the retina directly as a way to detect other forms of neurodegeneration for those that are listening or for watching. You know, I'm putting my hands up in kind of see shape. The back of your eye, is lined with these with this 3 cell layer thick thing that is the neural retina which are really pieces of brain. They connect to the rest of the brain. And because the resides in the eyes and outside the cranial Vault, people like you skilled clinicians with the
Appropriate tools can look into the eye and see the brain directly without having to cut through the skull. And my understanding is that more and more ophthalmologists are seeing cases where degeneration of the retina is correlated with degeneration of structures deeper in the brain making Imaging of the neural retina, perhaps one of the best diagnostic tools for predicting and tracking the progression of Alzheimer's and other forms of neurodegeneration. Do I have that right?
Yeah, absolutely.
Actually, this is a super exciting area. You know, we have this long-standing saying an Ophthalmology that the eyes are the window to the brain, the eyes of window to the soul, of course, is a long-standing saying. Right? And, and it turns out that, you know, in Alzheimer's disease as an example, you know, we really talked a lot about the degeneration of basal forebrain cholinergic neurons that are leading to the cognitive deficits in Alzheimer's disease. But it turns out that there is also some degeneration throughout other
Areas of the brain including the retina. And since we have such a relatively easy time Imaging the retina, you can go into your doctor's office and get a quick little sort of laser scan of the retina. A picture of the retina compared to like going through a full MRI process of for your brain and we can detect the degeneration of the retina and optic nerve associated with Alzheimer's disease. It looks like the same thing is happening in Parkinson's disease and Ms. Now one of the issues is that
That in a lot of these degenerative diseases, were able to detect the difference in the retina, but we're not necessarily able to say, hey if we see this in the retina it's multiple sclerosis. But if we see that in the retina, it's Alzheimer's disease. So there may not be, there may be good sensitivity to detecting the disease and to following whether your disease is your brain disease is getting worse, but there may not be very good specificity differentiating, the different diseases and I say that.
With a very big asterisk at the end of that sentence because there's actually amazingly cool new data. One of our colleagues who, you know, Alf do, bruh has helped revolutionize a new way of Imaging the retina that's giving us now, cellular resolution, and even subcellular resolution seeing things smaller than the sizes of cells inside our retina. And recently in one of his projects, he's teamed up with another one of our faculty Heather Moss.
She's a neuro-ophthalmologist so she really specializes clinically in the eye brain connection and her research focuses on that and together they made actually an amazing recent discovery of very specialized unusual novel structures that they can detect in the retina of patients with multiple sclerosis. And whether these kinds of discoveries or other similar kinds of discoveries are going to lead to kind of a whole new generation of biomimetic.
Markers, which are ways of measuring disease diagnosing, who has the disease figuring out, who's getting worse from the disease, figure out who's responding to therapies that were trying to use to treat the diseases, is a very exciting area and this really touches on what we're all, hoping is the future of I care as well as the rest of medicine and that's, that's Precision medicine. But also what we call Precision Health we really want to not just figure out what drug treatment to give this patient versus that treatment, but we really want to figure out who's it.
Risk of even getting some of these diseases and gosh, we could intervene now and prevent them from ever getting in trouble in the
future. Fantastic, can't wait to hear more about those developments. And listen, I want to say on behalf of the listeners and myself, just thank you ever. So much for the discussion today. I don't think I can ever recall a conversation that's included so much basic science, and clinical science, and also so many actionable recommendations, both do's and don'ts as it.
Relates to something so critical. As I health, I also was just reflecting for a moment about the fact that I think you, and I met 20 years ago, when you were a graduate student. By the way, folks, Jeff is sort of a Kobe Bryant of sorts. Although, fortunately still with us, in the sense that he went directly from his MD and PhD skipped. His postdoc didn't require one directly to being a faculty member. A most people don't do that. They do a five-year postdoc in between weight and then I believe he's gonna tell me all the places. I'm wrong. And I,
Just come clean. That Jeff is my chair of department at Stanford School of Medicine, Department of Ophthalmology. So for me I see this as a particularly warming but also at once unpredictable but pure pleasure of an experience to get to learn so much from you because I don't think we've had this long to sit down and talk science in a very long time. So thank you for doing that for my own sake. Thank you for teaching us so much about how to take care of our Eye Health. And now you can tell me where my
My history is wrong. Maybe my hippocampus is degenerating
now, it's been a pleasure over the years. I have nothing but the warmest memories of view as a postdoc in me as a graduate student, getting to be, you know, nerds in the laboratory 20 years ago, 20 years ago at Stanford in the lab of been beerus. And and very warm wonderful feelings about, you know, learning science and how to do science and making real advances, even at that time. And then the fact that we've had the chance to cross paths and
Diego again, at Stanford collaborate on important projects, having to do with, you know, developing new ways of measuring diseases developing new ways of treating diseases. The idea that we're going to actually bring forward some of the advances that are lab that you're a lab, that other people's Labs have been making in neuroprotection in diseases like glaucoma and macular degeneration in regeneration of the optic nerve of the retina. We're a real close on a lot of those. This is a major topic.
Topic of really the cutting-edge research that we're really trying to keep pushing forward because we know it's so important to patients, you know, I often joke, you know, my mother had a sign outside the bathroom and instead remember how long a minute is, depends on what side of the door you're on. And I really appreciate that. Like, as fast as we're trying to go with our research and moving that into clinical research, which I think we're doing very effectively in the department really working on vision.
Action research in the department. I appreciate that as fast as we think we're going, it's not fast enough for so many patients who are suffering from these diseases. So thanks very much for having me on. It's been a real pleasure reconnecting over these many important topics I really appreciate the chance to talk with you
know delighted to do it and looking forward to doing it again. You're an amazing colleague friend clinician and now public health educator. Thank you. Thank you for joining me. For today's discussion, all about I and vision health.
Dr. Jeffrey Goldberg. I hope you enjoyed the discussion as much as I did. If you're learning from and are enjoying this podcast. Please subscribe to our YouTube channel. That's a terrific. Zero cost way to support us. In addition. Please subscribe to the podcast on Spotify and apple and on both Spotify and apple, you can leave us up to a five star review. Please also check out the sponsors mentioned at the beginning and throughout today's episode, that's the best way to support this podcast. In addition, if you have questions for me or comments about the podcast or you'd like to suggest a
Is that I feature on the huberman Lab podcast. Please put those in the comments section on YouTube. I do read all the comments during today's discussion and on many previous episodes of The huberman Lab podcast, we discuss supplements. While supplements are necessary for everybody. Many people derive tremendous benefit from them for things like improving sleep for hormone support and for improving Focus. You remember a podcast has partnered with Momentis supplements. If you'd like to see the supplements discussed on the huberman Lab podcast. You can go to live momentous spell do you s so live momentous.com.
Huberman. If you're not already following me on social media, it is huberman. Lab on Instagram, Twitter, Facebook, and Linkedin, and all those places. I just got science and science related tools, some of which overlap with the content of the huberman Lab podcast, but much of which is distinct from the content on the huberman Lab podcast. So again, it's huberman, lab on all social media platforms. If you haven't already signed up for the huberman Lab podcast, neural network newsletter, it is a zero cost monthly newsletter that includes podcast summaries as well as
Protocols comprised of short PDFs that include everything from a toolkit for Sleep, a toolkit for neuroplasticity or learning tool kits for enhancing exercise tool kits. For enhancing various aspects of mental health, physical health, and performance, again, all zero cost and all available to you. Simply by going to huberman lab.com, go to the menu, scroll down to newsletter and provide your email. We do not share your email with anybody and again, it's the neural network newsletter and it is completely zero cost. Thank you once again for joining me for today's discussion.
Dr. Jeffrey Goldberg. And last but certainly not
least, thank you for your interest in science.
