Eyes Askance

Macular degeneration leads to irreversible vision loss in the elderly. Clinical research focuses mostly on curtailing the disease's later stages, but ophthalmologists say that more attention should be paid to early treatment and prevention.

Alabama artist Nina Pitchford learned to paint the forms and shadows exactly as they appeared. "You know a face has two eyelids, but you won't put both in. Perhaps you'll paint an eye with its shadow along the nose--what you see," she says. But Pitchford suffers from a progressive vision problem that strikes older people, so her world no longer looks the same. "I see a telephone pole is bent, but I know it's not," says the 69-year-old painter. Her art has become more impressionistic as a consequence.

Pitchford is not alone. According to the National Eye Institute (NEI), a part of the National Institutes of Health in Bethesda, Maryland, more than 1.8 million Americans suffer serious vision loss--including blindness--due to age-related macular degeneration (AMD). Another 7.3 million are at substantial risk for the disease. And unlike cataracts or glaucoma, AMD can't be fixed: The current treatments merely delay the deterioration that occurs in the latest stages of the disease.

Although ophthalmologists are seeing more cases, the elderly haven't yet put the condition on their personal radar screens. And experts say it's time they did. A public outcry could motivate funding agencies and researchers to step up their efforts toward preserving vision by stopping AMD before it takes hold.

AMD is particularly insidious because people in the early or intermediate stages of the disease are often unaware of the problem. Many experience little loss of vision and first learn of their affliction from a doctor who spies some yellow spots--irregular patches of cellular debris that the eye fails to clean up--on their retinas, the part of the eyeball where images are formed. These blemishes are an early indicator of AMD.

The macula makes up the middle portion of the retina, and its deterioration wipes out images in the central visual field. "What you're looking at disappears. You have to look to the right or the left and rely on your peripheral vision," says Pitchford. In addition, sufferers see straight lines as distorted or bent. A door frame "scoops out to the left with one eye, out to the right with the other," says Pitchford. "I hoped it would straighten out with both, but instead I'm seeing three or four dimensions."

Most patients with advanced AMD have the "dry" form of the disease in which the light-sensing cells in the center of the retina crumble. This atrophy causes serious vision loss but does not usually progress to blindness. AMD-related blindness almost always results from the growth of blood vessels into the retina. These vessels sometimes bleed and scar the macula, rendering it useless. About 10% of people with AMD develop this "wet" form.

Some retina specialists say that the United States has an AMD epidemic on its hands. In a recent survey of 100 ophthalmologists, 83 expressed alarm at the increasing number of cases of wet AMD. Although none of the current treatments slow the progression of early AMD, 71 of the specialists surveyed said that earlier diagnosis could encourage the development of such therapies, which might limit vision loss before it occurs.

Smoking and a family history of AMD render people more susceptible than normal. But the greatest risk factor for the disease is age. And scientists continue to debate whether factors such as sunlight, hypertension, and high cholesterol also put people at greater risk for AMD vision loss. "The research doesn't give a coherent picture of the causes or the pathology of the disease," says ophthalmologist Cynthia Owsley of the University of Alabama, Birmingham. The lack of a unified theory suggests that AMD is not a single disorder but a group of diseases with a variety of causes both environmental and genetic, she says.

Because researchers haven't sorted out the causes of AMD, they've tended to pursue stopgap measures to stall the worst outcomes in the late stages. Some approaches have focused on diet. For instance, the Age-Related Eye Disease Study sponsored by NEI in 2001 followed 5000 people at risk for AMD and gave some of them a daily supplement containing vitamins A and E, beta carotene, zinc, and copper. The treatment kept the vision of individuals in the middle stages of the disease from deteriorating further: It reduced the incidence of advanced disease by 25% compared with subjects who didn't take the vitamins. But the supplement did not keep people in the earliest stages from getting worse. In another, ongoing study, investigators are examining whether other nutrients with known vision-preserving properties, such as the lutein found in green leafy vegetables, will help stave off AMD.

Researchers are also scrutinizing drugs that physicians inject directly into the eye. Retina specialist William Mieler of the University of Chicago, Illinois, says that an array of pharmacological agents designed to combat AMD's 11th hour should reach people soon. For example, drugs that interfere with vascular endothelial growth factor (VEGF), a molecule that stimulates blood vessel growth, could help prevent blindness in people with wet AMD. Eyetech Pharmaceuticals in New York City expects its anti-VEGF drug, Macugen, to win Food and Drug Administration approval by the end of 2004.

Although these leads are very promising, none of them will prevent AMD or treat it before the damage is done. Public awareness could help, says Owsley: Once people realize that the disease might strike them--and that available treatments only work once vision loss is severe--"they will stimulate the government and private agencies to put more effort into solving this public health issue." To engage the masses, Owsley and the University of Alabama have recruited artists with AMD such as Pitchford to put a face on the disease.

Until better treatments or cures become available, people with AMD will have to learn to live with bent lines and peripheral vision. Perhaps, Pitchford says, her altered eyesight will move her into another phase of her career. "I will paint these distortions, rather than trying to pretend I see a landscape, house, or a person," she says. "I don't know if there's a market for it, but if something happens to be the right color, people will buy it." And if a future treatment happens to stop AMD, seniors will buy that too.

Mary Beckman is a writer in southeast Idaho who couldn't paint the beautiful desert sunsets, no matter how clear her vision.

National Eye Institute http://www.nei.nih.gov/

University of Alabama AMD Information site

http://www.eyes.uab.edu/ARMDinfo/

Eyes on Art: Artwork by people with macular degeneration http://www.uab.edu/eyedoc/right.html#article3

Aging Times http://www.agingeye.net/maculardegen/maculardegeninformation.php