Dr. Jeffrey Goldberg: How to Improve Your Eye Health & Offset Vision Loss
02:42:06 Share

Welcome to the huberman lab podcast, where we discuss science and science space tools for everyday life. I'm Andrew huberman, and i'm a professor of neurobiology and optimal gy at stanford school of medicine today. My guest is doctor Jeffery golden g. Doctor Jeffery golden g. Is the chair of the department of apotheoses gy at stanford university school of medicine.

He is a clinician, md, or medical doctor, who see patients every week, as well as a PHD, meaning laboratory scientist who direct his own laboratory focus on understanding the mechanisms and cures for diseases of the eye and vision, such as gloomy retina, united pigmentosa and macular ity generation. Indeed, doctor golden g is one of the world leaders in developing methods to cure blindness. He is also intensely knowledge able about all things related to vision.

So during today's discussion, we indeed cover most all of visual and I health. You learn, for instance, about the benefits as well as drawbacks of wearing corrective lens ses, such as contact lenses or eyeglasses. For reading, you will learn about the benefits and detriment of sunlight, meaning how I can help your vision, in fact, how I can help reverse or prevent iope a near side in this, as well as the things to be cautious about with respect to sunlight in terms of development of cater acts, which are conclusions that prevent vision, we also discuss many tools for maintaining and improving vision across the lifespan, ranging 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 lactic surgery. We get into all the details of princess, how often to do these various I exercises, how long the benefits are maintained, as well as age related considerations for things like lastic eyes surgery. We even get into how to best clean your contact lenses, whether not to use disposable contact lenses or other forms of contact lenses.

We also discuss things like dry eye and the best remedies for dry eye. And we talk about the scientific and clinical data around nutritional approaches and supplementation based approaches for maintaining and improving vision. So whether not you suffer from floors or dry or you are considering changing your eye prescription, or you have concerns about whether not relying on corrective lenses is impairing your vision and you want to enhance your vision, or if you 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, retina, tis pigmentosa and macular gy generation. 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 doctors, golden gs incredible knowledge, his clarity of communication and his generosity with that knowledge, by the end of today's episode, you'll 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 erles at stanford. IT is, however, part of my desired 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 sponsor of today's podcast.

Our first sponsor is element. Element is an electoral light drink with everything you need and nothing you don't. That means plenty of salt magnesium in patasse, this so called electronic light, and no sugar.

Now, salt magnetism in patashie are critical to the function of all the cells in your body, in particular to the function of your nerve cells, also called neurons. In fact, in order for your neurons to functions properly, all three electroliers ts need to be present in the proper ratio. And we now know that even slight reductions in electronic concentrations or dehydration of the body can lead to deficits in cognitive and physical performance.

Element contains a science back electorate ratio of one thousand milligrams that one gram of sodium, two hundred milligrams of plastic um and sixty milligrams of magnesium. I typically drink element first in the morning when I wake up in order to ate my body and make sure I have enough electoral lights. And while I do any kind of physical training, and after physical training as well, especially if i've been sweating a lot, if you'd like to try element, you can go to drink element that's element dot com slash huberman to claim a free element sample pack with your purchase.

Again, that drink element element t dot com slash huberman. Today's episode is also brought to us by waking up, waking up as a meditation APP that includes hundreds of meditation programs, mindfulness trainings, yoga ea recessions and nsd r non sleep depressed protocols. I started using the waking up up a few years ago because even though i've been doing regular meditation since my teens and I start doing yoga eja about a decade ago, my dad mentioned to me that he had found an APP turned out to be the waking up APP, which could teach you meditations of different durations, and that had a lot of different types of military to place the braining body into different states, and that he liked IT very much.

So I gave the waking up up a try, and I too found IT to be extremely useful, because sometimes I only have a few minutes to meditate. Other times I have longer to meditate. And indeed, I love the fact that I can explore different types of meditation to bring about different levels of understanding about consciousness, but also to place my brain body into lots of different kinds of states, depending on which meditation I do.

I also love that the waking up up has lots of different types of yoga ea section, those you don't know. Yoga eeda is a process of line very still, but keeping an active mind is very different than most meditations. And there is excEllent scientific data to show that yogananda and something similar to IT called non sleep deep breath or nsd r, can greatly restore levels of cognitive and physical energy, even which is a short ten minute session.

If you'd like to try the waking up up, you can go to waking up dot com slash huberman and access a free thirty day trial. Again, that's waking up dot com slashed huberman to access a free thirty day trial. And now for my discussion with doctor Jeffery golden g. Doctor Jeffery golden g, welcome.

thanks. Is 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 I health and course as a news scientists 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 place to get those answers. So kick things off.

I want to ask you what was one of the most commonly asked questions when I solicitor for questions in anticipation of this episode, which is, how early should one do an eyes 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 so how and how often should they check in? What kind of information is there?

Yeah as a great question, obviously something that touches a soul. So the the answer that really differs a little bit at the different stages live. First of all, every every baby gets an exam or should be getting an an exam. And one of the main things that you really just screening for a right when that baby is born, right in the nursery, right the first few days, is to just look for a red reflex.

You know, when you take a camera picture of flash picture and sometimes you get red eye, that's actually the light from the flashes, you know, reflecting against the retina coming back out of your eye looks red and and a red reflex is actually very Normal. That's great. And if you have a not 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 retinoblastoma, which is the most common pediatric eye cancer, a which you can thankfully quite rare, uh, those babies won't have a red reflex in that eye.

It'll be kind of a White dish or gray reflex. And so even just that first little, you know, doctors taken a little penlight, even just flashing IT in in the baby's eyes. So that's that's our first I examine. And hopefully we've all had that. And hofus ly, every baby being born today is getting that getting that first I exam is really just looking for that red reflex uh it's not typical as long as that's looking good um to worry about getting an exam from their kinds through um childhood like maybe early elementary school in less they beat 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 the first couple of years, you through the first couple of years, babies actually don't have great visual acuity.

And so as they are aging over those first couple of years, it's Normal for them to, you know, roving I movements, for example, be searching their environment, but over those first couple of years of parents start noticing the baby is, 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 and anything like that, of course you're going to a trigger trigger and I exam. But otherwise most babies, other than their pediatrician, doing that red reflects jack when they are 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 an Amber opium screening exam. If kids eyes either if one eye doesn't see that well, like maybe you're very near cited or far cited in one eye and pretty Normal cited in the other or the two refractive errors are quite different from each other um that can lead to a condition you've talked about on the podcast before called Amber opa, which is probably one of the more common or most common eye diseases of children or if the eyes aren't a line, you know, our eye muscles in the brain behind them are really responsible for keeping the two eyes looking straight ahead.

And if that's not working properly in one eye is off culter. And therefore, the image of what we're looking at is falling on different spots. The retina is not sinking up right in the brain that can lead to this disease condition called embley opa, where that eye is no longer talking to the brain properly.

And there's a pretty easy screening exam that can be done for your business, the misalignment of the eyes that kid'll do in elementary school. The other main presenting symptom of kids in elementary school is when they admit to their parents, I can see the board or I can see the teacher up front and then they might be quite near cited. And so that will also trigger an exam. And ah so those are usually the parts for for babies, for todd's, for children, school age children that might reasonably triggered exam.

A couple of questions about early I exams and will get onto exams and other individuals in a second. But I want to interrupt with this question. So you mention that um there can be a missile in 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 I might correct but sometimes still have a we don't want to get technical here for our listeners will keep IT general but either convergent eyes or one ee converging crossed or wallie again using that non technical language here. Um and my understanding is that the brain is taking that information in and is very plastic.

It's changing in these early stages 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 rather that the brain cannot learn to handle the proper alignment ment. So in other words, if the kid has cross eyes, crossed eyes, excuse me, and they're not corrected until they are twenty years, it's possible that they will never recover Normal vision, where as if you cover, if you alone's ed properly early in development, they can indeed recover vision. How early can and should one consider getting those eye realignments done? Yeah, yeah.

pretty much right on what we'll do is if they detect any I misalignment. And sometimes parents are or good at noticing. That is, sometimes you take a picture, and one I got the red ye reflects and the other one did in. And sometimes people notice that their kid's sizes are turning in IT seems like too much. Um sometimes there's what's called photos, a business which is we're actually depending on your anonymity, if you have a little extra skin on the inside corners of your eyes makes your eyes look turned in when actually they're straight.

Um but if your eyes are actually turned in or slightly less common in children or common in adults misaligned turned out um it's really important to correct that early and the reason is as you were saying, the brain starts ignoring IT 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 thresh holds 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 of we used to use very sort of a you know, growth numbers like fully correctable if you can intervene before age three, partly correctable if you can intervene before age sex, you've got a chance before age nine. But IT turns out and follow on studies that even kids into their Young teens have a shot at correcting that eyebrow connection that ebi opa, that that loss of vision ah 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 twenty years or early teen years, it's still worth to try to really push to um retrain the weaker eye and then also realigned the muscles so that they can work together to keep the eyes focus on talia.

It's interesting and there's a lot more to learn about brain plasticity and probably a lot of really cool new therapies yet to discover that could reopen what's called critical period plasticity, this this this plasticity that we have during development that kind of goes away as we age. And and that critical pair plastics, you know, has been the best studied actually in the visual system. And the idea that we could reopen that israel, fantastic.

But for different parts of that eyes, brain connection is different periods for critical period, classically, for example, even if you get the Amber opic eye, see well again, and then you realize the eyes, and they are working together, a lot of kids will never recover. Full depth perception story options, 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 can ask for curbside consult, as sometimes called right now, by telling you a story. When I was a kid, I went swimming without goggles, and I had one eye closed and the other eyes open and closing as I went in. Now the water, because I deficient swimmer, and I only breathe to one side unless i've really consciously forced myself to breathe both sides in a freestyle swim, got out the pool and I was seen double IT was pretty easy.

And then I became downright scary because I didn't recover my double vision until they patched one of the eyes to 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, was about a day or so. I read what Normal vision, however, my debt perception is terrible.

Um and the kid that you fly ball was IT to me in the outfield. Ance coming, coming in. Then IT hit me. This is why I generally focused on foot sports throughout my life. Is supposed to you precise hand eyes ordination and Better throwing guards and things with one I close than I ever would be with both eyes. Maybe that's true for most people.

Question I have is, is, is 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 correct tive measures and such as patching up one eye and the example I gave us just one. But for instance, if um um you know someone in you know get a scratch on their cornea and they close, they patch the eye and the person happens to be ten years old, is IT important to then patch the other healthy eye after the the um you know the scratch eye 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 a has some features of, uh you know totally usual how we think about missing eyes leading to Amber opa, or one eyes weaker, patching the strong eyes the week I can recover, but not necessarily fully regaining depth perception and so that part of IT is you know quite stereotypical the part of your story that's a typical is that for most kids um an hour to let alone minutes, an hour to even an hour to a die.

If you are I don't know if you are a Young kid and you just really were training up on throwing darts, and you are just keeping one eye closed to throw the darts, you really practicing for an hour die IT be very unusual for that to trigger this kind of either through business business alignment of the ice letter and Amber opium. And this for business is what's giving you the double vision because they're missing line, let alone the ambition. Ia of one ee 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 inter mittens business and your grain was already getting kind of hit and and you neither you nor your parents may have even noticed that, that could be happening you know at other times a day or you're not kind of really paying attention. IT doesn't kind of stand out in the way that that that day that that you got out of the swimming pool, all you really noticed.

And IT may not have been that strong. IT may been quite important. But if you would have some years of inner mitton eza roya or turning in of the eyes, or exeats pia turning out of the eyes, that just happened here and there, but was accumulating sort of uh, 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 that that LED to an I exam at an I care provider, and they had, wait a second, this size stronger, this size weaker. You've got a little Amber. Hope you we're going to start patching your strong eyes. You can get your weak eye back.

So for ninety nine point nine percent of the kids who like, you know, they get a little corneal scratch or they are patching when I closed or or you know anything that 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 that kind of thing and and not after worry. And and it's unfortunate we can't tell an advance which kids been having the intermet nyorai.

We don't do a standard of exam on every five year who's not complaining of anything. But but yes, 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 subclinical on tract, uncharted, unnoticed maybe for business leaving up to that point.

And thank you. You can send me a bill at the end along those lines. And forty seven years old. So I was part of the generation that grew up with some computers in the classroom, meant on a lot. A 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 I ball lines 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 biopic c or near sided. What can we say about the environmental conditions in which kids are seen from the time they're born through, let's say, adolescence and their teen years in terms of how their visual system wires up? And are there any recommendations that are coming from the scientific literature, clinical studies, clinical trials, excuse me, otherwise, that indicate what a healthy visual environment .

consists of? Yeah, yeah, that's a great question. And I actually it's really relevant these days because uh you know my opa is so common um it's more common um in asian populations. It's called an epidemic in china. Uh 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 um you know my opie in kids and adults and really starting yet thoughtful on the science of my opa control. How do we how do we provide the right environment? Now what's interesting is that for decades the assumption sum of the.

Really let us to the path of thinking like, gosh, the more you spend a near activities and is mouse model experiments like you described, but also well designed human cohort studies, you know figuring out like asking, you know, kids and families, like how long as your kid reading or in front of the computer how my topic are that, how your site that are that versus is how much time is your kid in front of the computer doing near work? How my optical near sided are they? And these well design cohort size did point towards this concept that if you do too much network as a kid, that you are more likely to develop your sighted this as you get through those though, sort of you protein, and even into eighteen years, which is when most of that miotis progression, or I ball elongation is actually happening to cause your side to desk.

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 new activity, but maybe it's not all about new 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 theyve now studied and asked the kids, instead of just how much near and how much far are you doing, how much time you spending indoors in indoor lighting, which doesn't have full spectrum light in a typical indoor environment, versus how much time you're spending outdoors playing in the yard, you could be reading outside. But what are you what kind of time are you spending outside? And and and of course, when you're outside in sunlight, even it's a direct sunlight, you're getting a different 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, then just near work. And so I think that you know we've we've actually already seen the first couple randomised 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 in door time and uh 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 near sightedness. Ss last like their their near cited prescription is not getting as strong as the kids are spending more time indoors. And there is 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 uh, concept and and so you know as a parent, uh you 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 if your kids planned on the phone or something like that or the ipad or something like that, there are well, 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 threshold for the amount of time that one would suggest their child be outdoors? Um to get that full spectrum light.

it's a great question. You know we talk 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 call a dose dependent response.

Maybe the more time outdoors might be Better. We don't know if there's an Opera limit like gosh, if you go over two or three hours, there's no additional IT talk about that. And coward studies, the real gold standard for answering these kinds of questions are randomized controlled trials and specifically placebo controlled or 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 random ze kids, to telling 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 I got 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 zero and one or two hours, clearly there five minutes enough is five hours Better. I don't think we know the answers to those questions yet like what's the right dose, but there's probably at least some dose dependence to that.

And if I can imagine it's a little bit hard to teeth 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 here. So and perhaps IT isn't important to isolate these variables, although I can see the chAllenging developing a really good clinical trial, reno, my clinical trial for this. Meanwhile, I I know I can't 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 circle yim.

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 are any data in older people, not necessarily elderly, but older people? So people on there are from, say, twenty five years of age into their sixties or seventies, that getting out ours and getting this full betray 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 in most patient, most people, the the development of near sightless happens a lot until age ten little more through age twenty little more than that into the you know in through the twenty up authority, tiny bit in the thirties, up to forty, but usually by those later ages.

Your prescription might be changing a quarter of a die opt, or that the measurement that we use when we know give you your glasses prescription. A quarter of a director, half a director, IT could get a half director more near cited or less new cited. You know, once you're aging into your forties, fifties and beyond.

So most of the action on near side of this development is actually really happening in the Younger ages. So again, the premise of in 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 radiation to do that general. Um I think the the the premise of of of of sort of light modulation for near sighted ess in older people is probably probably not so strong.

I think there are a lot of other benefits. You have talked a lot about the cadia rythm. There are so many health benefits to exercise. And you know if you're getting outdoors, there's a good chance you're going na be walking or bicycling. 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 now in our forties or fifties or beyond.

I'd like to take a quick break and acknowledge one of our sponsors, athletic Greens. Athletic Greens, now called ag one, is a vitamin mineral probiotic c drink that covers all of your foundation tional nutritional needs. I've been taking athletic Greens since two thousand and twelve, 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, are usually twice a day, is that IT gets to be the probiotics that I need for god. Health, our god is very important, is populated by got microbial to that, communicate with the brain, the immune 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 microbiology alth.

In addition, athletic Greens contains a number of adaptations in 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 athletic Greens, you can go to athletic Greens dot com slash huberman and theyll 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, at sea, and they'll give you a year supply of vitamin d three k two.

Again, that's a letter Greenstock comes slash huberman to get the five free travel packs and the year supply of vitamin d three k two. Probably worth touching on some of the dose and some of the dots for eyehe alth generally. And then I promise someone to get us back to adult exams because of a lot of questions about that.

I can imagine that it's probably not a great idea to be exposed to extremely bright light. And this is why people who welled wear 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 um including brightest of light.

We touch a little bit about near far um obviously want to keep toxins and assets and solves and things out of the eye. What do you see? I'm like hopefully not commonly. But what are some of things that you feel might not be discussed enough in terms of .

I health yeah you know I think at all ages ice safety is something that we don't talk about enough. Um you know our eyes are kit, the front surface of the eye, the cornea, the clear window that lets the light go in. R.

I, that's a delicate, very sensitive structure. It's thin, maybe a millimeter at the thick half millimeter in the center of I. Uh, the retina is its its neural tissue is like really an outgrowth of the brain.

This is very sensitive. It's subject to generate disease and injury. Our eyes, even if they just get hit, can get very inflamed. Our eyes can be more inflaming than a bruise on our skin, on our shoulder might be. So I save these a big one in people who are um working in certain industries.

Um you know anyone is doing any metal grinding people who are even just gardening, you know and if you if you're doing some significant gardening and cutting and you could you know flag a little bit of dirt, there's a lot there's a lot of, for example, fungus that lives in the ground, natural stuff. It's all very Normal in the earth. But you know our eyes are really.

Need to absorb that fungus and and have a piece of dirt kind of a stick in our eye like that. And so people are at risk, I think, for you know for not. And we see too much kind of really unnecessary ee injury, ee trauma that if people were either the glasses because they happen a where prescription glasses or goggles or for more advanced to work safety goggles, of course, um if you're sending doing woods shop projects, anything like that signing, including you know again in the garden cutting things. Um you know I think I think I safety you know I trauma is a big one in you know we probably see one or two um what we call open globes a week come into the Opera into the emergency room and um you know those are tough because you know again, the eyes delicate, you 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, is just a little more education around around ye protection, protecting against eyes trauma.

What about eye cleanliness? But there are some pretty dramatic videos also. I put some of these on my instruction handle. These are mrs.

Of people rubbing their eyles, and people really getting a sense of, first, all of repayment of what you said, getting a real sense of just how much the eyes are an outgrowth of the brain because of the one you see them with the optic nerves and all their beauty and the ebs moving around as someone rubs the eyes. I I have to imagine that rubbing I balls a little bit is in bad, but actually called you. I don't.

If you remember, when I was A A junior professor, I woke up from an apple one day and I couldn't see at one eye freaking out. Of course, I called you and I had pressure, blinded myself by falling a sleep on my hand or something like that. And you assured me that my vision would come back.

And indeed, IT did. So you played the role of optimal gist and psychiatrist. Thank you. And indeed I can see at both eyes. Um no but. Rubin, our eyes getting guns, 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 that happens, IT is truly frightening that were so dependent on vision.

So um you know what are your recommendations about rubbing or not rubbing eyeballs about handwashing and cleanliness? And also how do you wash and ee properly? Do you use soap and flush IT with water? You just flush IT with water. Should you not even do that, you use sAiling. And he realizes these might sound like low level questions, but these are the things that people deal with on on a all too frequent basis.

Yeah, you know, for most people, most of the time, actually the eyes are a very good clean environment and actually are tears are are a contain enzymes that help break down bacteria and bacteria toxins.

And so for most people, regular eyes washing doesn't have to be part of their standard routine in terms of the surface of the eye, the part of your eye, the conjuring tava over the Whites of the eyes, underneath the islands, anything underneath the islands, it's pretty self cleaning. And actually our tear production and blinking is very good at keeping our eyes clean. Uh, the eyelids I lashes can be another story.

And especially as we age, uh, 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 nicknames curve, which is like a little dead skin bits that accumulate on the eyelashes. A lot of people develop up what we call blueridge s, which is just means inflation tion of the eyelashes.

Yeah, and for that, doing some ice grubs is a good idea. They actually sell a little pads that you can buy, kind of little that you rip open, and you can use to kind of lightly clean the l ashes. But you can also just use like a no more tears baby shampoo, just pump a little bit into the palm of your hand twice a day, let a little delude IT with a little water and under the sink, and do either with your finger or edge of a wash cloth just very lightly rubbed eyelashes.

What I like to do with the eyes clothes .

with the eyes closed and and don't scringe them close to type because you're actually burring the eyelashes when you do there, the roots of the I lashes when you really scratch rose.

So just gently close your eyes, just, you know, a real gentle closure and then just lightly scrub IT shouldn't be a great if you're not trying to exfoliate the eyelids or mashes in anyway, just lightly rub with that kind of dilute, no more tears, baby's champagne and that can really help people with their eye comfort if you feel like you ve got something in your eye. Your ideal eyewash is actually going to be a sterol salian solution, a salt water solution. You they sell little bottles over the counter, uh, eyewash solutions like that. A lot of people where contacts will have that kind of eye wash solution, just a sterol selling I wash, just peer salt water doesn't have to have any other chemicals or preservative in IT.

You can of course use not .

actual a seawater salt water. T thank you. T out of of the ocean, but like a saline salt water that's available in a sterol. Now you can also just use artificial tear drops, and some of those come on non preservation, some of those common preserve versions, those are all also completely safe and to use in the eye.

And there you you know, you can sort of spirits into your eye and hold a little open and give you a little spirits if you feel like you got something in your eye piece, a dir or a lash that's not coming out just to ins IT. But but having like a regular routine, you know you're not gonna heard anything with the occasional ee robbing. We all do these things just kind of as a, you know even a nervous habit or just absent mindedly, you know you might you know scratch your ARM and rubb your eyes or things like that.

That's fine. You're going to heard anything. Uh, 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. I rubin IT can be dangerous if you're in that group.

But for the regular run of the mill every day, occasional I rubbing fine, if you're certainly, you get a lash, nair, and you're trying to rub IT, blink IT and tear IT out. And again, in that situation, you can use some artificial tears, wedding drops, 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 a piece of the brain literally lining the back of each of our eyes like like a pie cross. I mean it's really remarkable um biological system, of course I don't have to tell you that is just IT never sees to to amazed me. Let's talk about I exams and adults. So people are aware, presuming bly, that there optometrists and optimists, I think it's important that we define their different and also overlapping roles.

And for those that our past high school age probably not getting eye exams unless they're sensing a problem, perhaps not even with blur, revision or or difficulty seeing at a distance, but sometimes just what IT feels like, fatigue of the eyes or a hard time maintaining alignment of the eyes um so how often you recommend people get I exams? What is a true regular eyes exam? And is this important that people go to an optimal gist? Or will an optometry office? Typically optometry are a little bit easier for most people to access because there's usually won some place near an eglu store. Um so what are the rules? How often shall we get our eyes checked?

Yeah um optometry and ethnologists do have very overlapping roles in being, I care providers. There is something over forty or fifty thousand of palettes need that say it's there's somewhere around twenty thousand photo logic in the united states. Optometrists get an optometry degree, they often have od after their name.

Psychologists usually went went to medical schools, they they have an md after their name, or they kind of a deo version of a medical degree. And and then optometry will have done additional clinical training in that area, in their area of I care provision. Opsm logic md doctor opened ologies I care providers, in addition to that training, will have done a surgical training in authority.

Gy, now there's a lot of overlap. And in both scenario, you can be getting your sort of general exam taken care of, maybe screening exam. I think that there's been a traditional differentiation between optometry and automotive gist with optometrists providing a little more of the primary care ice screening, maybe managing early disease, common diseases as well with more advanced disease often sort of upgrading to perhaps specialist of theologist in those areas. But that distinction has been uh, declining over time.

It's still true that in I think most of not all states only the md automotive gist, uh surgeons can do I surgeries but um both both groups of care provider can diagnose both can prescribe appropriate eyedrops treatments including prescription eyes drop treatments for for many of our diseases, eye e diseases and um and in some states optometrists have successfully lobbied for uh sort of expanded rights of providing air care, eyes care and again um access to care for you know the regular person wherever they may live as is the most important element. And so being able to access eye care, whether it's with an optometry in your community or an open ologies that may be in your community or may be at a distance, I think that's the the really important thing is to access care. Now kind of like we're talking about with kids, if you're in your teens twice, maybe even thirties and not having any problem, you've got no complaints.

You can see a distance, you can see IT near um you know so you can read without glasses, you can drive without classes um you're not having in a eye pins pins around the eyes you know redness of the ice you may never present to an I care provider uh through the first four decades of life and almost all the time it's gonna be OK 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 going on because there are some diseases.

Glow coma, for example, my special day, the two main risk factors for glow koa are increasing age. And IT usually presents, you know, most cases actually after age forty, but also increasing ee pressure. And if your eye pressure is too high, you can feel that that won't feel funny to if IT sort of slowly as crapped 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 care. 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 IT started in trouble. Could somebody say I like my precious checked as I recall the optometry, they can do a puff test so they going to blast a mir, get a sense of how how rigid or or um soft again, using non clinical nontechnical language here that the eyeball happens to be not 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 eyes.

Ls, and I only only have joking. Please don't do this, folks. Given the conversation we just had about I cleaning ss and I roving, my understanding is that the old are truly old fashioned eye pressure exam was he would close, arise, and the author logic would gently press to see whether or not your eyes were more rigid than last time. Is that right?

That's called allotment. And you can kind of you you can kind of just take one second if you're listening and press on your eyes just very lightly. And yeah, 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 he feels under the eyelet like, gosh, something under there is a rock hard, then we know something is wrong. That is way too high pressure of its rock card.

But i'll tell you our ability to differences, the fine points of high pressure other than rock, hard or not rock, is pretty limited. So yeah, the automatic office or the opened ologies office as part of a comprehensive screening exam. They'll check the eye pressure, they'll look at the surface of your eyes, make sure everything's looking healthy.

They are including the eyelids and lashes. And they'll look inside the I and be able to screen for these diseases that way too. In addition to checking if you're complaining of any you know blurry ness at distance or IT near now.

After age forty or so, a lot of people will present to an I care provider because we all get what's called press bio, bio and press the opp. A just translates to disease vision of the agent. So, you know, my oppoa is our word for near cited hyper, oppoa is far cited, actually etr pia means Normal cited.

So I can see IT distance without any glass design. Amateur pa, but then we all get press bio bia. And as we aged, the lens inside our eye that's helping focus light onto our retina gets stiffer such that our eye muscles are no longer able to relax and reshape that lands.

And we're not as good as we age at moving our focus from distance vision. Distance vision, by the way, basically anything three feet or further away, you're basically viewing light rays coming from infinity at once you're past three feet. So three theater further being able to focus that in the fourteen inches or twelve inches, which might be a Normal comfortable reading space for you.

We lose that ability to flex our lands, relax our lands, uh, refocus our lens from distance to near. And most people around age forty could be a couple years before, could be five, ten years later. That, you know is that but sort of around that time, you start needing reading glasses.

You need a little extra 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.

I'm really intrigued this, but maybe you could clarify when you say reading glasses, do you mean just a magnifier? Because I use, you know a point five or a point seven five magnifier for reading, but I try to rely on them as little as possible. And I want to get to this about using glasses as a crush in the problem with that.

I have a story about that too. I am think it's no coincidence I decided to work on vision. I mean, after all, had a bunch of vision issues that fortunately are corrected. But you know, I do experience for this 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 look 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 is extremely blurry to the point where i'm calling jeff, i'm afraid. But then over the course of maybe ten, fifteen minutes, IT resolves. And I don't think it's because something in my eye, I don't think it's pressure of having slept on that side.

I it's a lubrication of the eye issue but the two eyes 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 often um if I want to read at night something that so just IT feels so much more relaxing, I feel like I like I can finally relax where as otherwise I realized that i'm training in order to see this. Is there any clinical clinical data and .

what I just described? Yeah you know and i'll tell you a my story that's like that and um we were living down in Sandy ega when you and I were both professors that you see sand ago and uh we had moved into a house and I found a pair of glasses, a pair reading glasses in a closet and you know we asked around, you know, did any 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 glasses you know, in this in the back of this clause set.

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 was. And this is back.

I was about forty, forty two, something like that. So so I didn't even realize until I put on the readers. And these were one point two five, so often five miles and italia.

I got addict IT, because who doesn't like good vision, right? I mean, of my god. Now I can make a type smaller on my phone I know .

was wonderful. I've been the muscular ure that's responsible for for moving the lens and focus on the eye and all this extra ocular musculars. And we forget me I am definite fee um around my eyes um probably because I squint or something. But you know, just the ability relax one's face IT just feels like you more more energy, I feel like, can be devoted what we're actually looking at. Yeah, not making light of this.

Well, pretty soon, I just kept that one per glasses with me all the time, and I would just keep him in a pocket and whip him out. Whenever I was still working at near, using my phone at a little greater distance, like a typical computer distance, I could still see the computer finds. So really started for, like, kind of that close up phone.

I 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 ten pairs and leave them one by the bedside table, you know, one in the car, one in the computer bag, one on every just yeah because I leave them anywhere and forget them in that way.

I just yeah exactly so um yeah. So whether using the readers accelerates the progression of dependence on the readers is still, uh, 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 if you're not straining your muscles and all of a son, the text on your phone looks crisp. E, R, again, boy, that's addictive. You, you're gonna 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 a little bit out on that point.

By point being your either either way, your dependence will grow. And as you continue to age, forties, fifties up until about sixty, sixty five, the ability to shape that lands gets weaker and weaker and weaker. And so you need to move from the point fives to the one point out to the one point fives.

And the good part, the thanks fully.

not you eventually max out at about plus two point five or plus three because that's the amount of extra reflective power that you need a magnifiers to take the equivalent of your infinity viewing and bring that up to fourteen inches to read IT near. Basically you need a plus three and then you don't need any lens, I muscle action whatsoever. So you kind of max out around two point five or three.

So because most people will hit that somewhere in their forties, that 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 that like my I guess I should go to the eye office, right, to see the optometrist or maybe optimus gist. And when they go in, they should be getting a standard in either of those offices.

Will be to give you a full screening exam, including maybe it's the puff tester, a blue light tester, a little pen that that can check your eye pressure and having a look inside and seeing if you're written an object nerval healthy. It's kind of screening for all the main diseases. And so and we'll tell you at that point, hey, you'll look great if you feel like your glasses aren't done IT for you in a year or three years, come back or they might say, hi, i've detected something. I'm worried about you and we'll set up a routine for your .

ongoing eyes care assuming that somebody doesn't have you know some form of ameobi a or the need for some a really robust corrective lenders. And they are already using readers, let's say, a plus one or so you plus one plus r minus point five 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 are 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 bit more after other words. Are we weakening our eyes by using these these readers? I realized you said that the data little bit mixed, but as long as one can perform the require daily activities, would we be Better off delaying the use of readers?

There's two important answers to that question. One is regarding the lands and the eye muscles that control the lands. And it's entirely plausible that's what I was saying kind of the data mixed one, but it's plausible that if we were just exercise like work a little harder, kind of not use as strong as reader as we ve won or not use that reader as often as we might really enjoy, uh, are we exercising those muscles and kind of exercising the ability to to to stretch versus relax the lens and kind of slow the progression from the one point of reader to the one point two five reader to the one point five reader at such a right? And so that's why I saying the data mix, 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 sharp 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 reading glasses or leaving them out or you're not helping the whole back party is maybe 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 enjoy your best vision all the time. And if that means wearing glasses, and by the way, if that means that you're gna have minus two glasses for vision and you'll eventually need minus two fifties for distance vision, or if you're going to need readers one point five readers now and in a few years, two point o readers, okay, so you'll get the next reader, it's it's actually not a big deal.

You you, you know you're not you're not hurting. You're probably helping. And in the meantime, it's an enormous enjoyment to actually have good vision all the time, right? so.

So I actually counsel people just where the glasses that work best for you. You know you're only minim ally changing how your prescriptions going to change over time very minimally. So just enjoy your best vision even if it's using readers for close or or prescription glasses for far.

Appreciate that recommendation. I do enjoy using the readers at night 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 for a number of years, are there any I know there is something called stationary nike blinds. I don't think i'm stationary nightly. Ind, um I think the mutation for stationary night by us was identified in the callus a horse or something like that.

These are horses that you could walk up to very easily and they won't even see you until you're right there. Someone's going to correct me on this is the internet, but I think that the mutation was identified and said her. But I don't think i'm stationary nightline, but I do find that driving at night I get very fatigue and then 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 lenders? Um and what what source of biology underlies ed that assuming that somebody is not stationary nightmare or a callus I think is the name of the breed horse yeah that's .

a great question. You know we for the for the optical defects in our eyes, most are many of which can be corrected with just having the right prescription lenses. We can get away with that without using those corrections in brighter light.

And so during the daytime, um you know uh you could be slightly blurry, you know if I have a real bright light uh 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 find 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 at night because we can make up for a lot of that blue r if we just have bright enough signal and contrast coming into our eye. Make sense yeah.

So when you're driving at night and noticing this, this might be revealing a little bit of a need for glasses. Now i'm not suggesting this is the answer, but far more common than having congenital station nightline's would be being what's called a latent hiper rope. okay.

Now we talked about already how the lens inside our, I goes from focusing IT 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 or designed or sort of set up in length, not for regular distance, which would be anywhere from about three 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 occurs 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 to to to use those muscles, strain those muscles, relax that lands, round up that lands and have your vision focus from beyond infinity to Normal distance, like distance vision. And so if you're a late in hybrid, 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. Uh, you're little hyper roya. Or by the way, if you've had a drinker to, uh, alcohol can do this to your late hyperbolic can kind of kick in, especially where age you are, not as good if refocus that lends anyway.

And now of sun, your vision is kind of reverting to its natural state, which is slightly out of focus at distance, because it's actually focus beyond infinity, if you will. And so all of the time you put on that plus one just for a little extra booster cake, you're like, oh yeah, yeah. Distance vision is clean and easy now.

So i'll have to bring into the clinic to really be sure. But you could be exhibiting a little bit of that kind of late. And hyper roba definitely .

want the I exam, and I want IT from you. And i've been called a lot of things in life. And we can now let add perhaps late and hyper opp to that, another peace here.

And again, this discussion is not designed to be an 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 not to rely on correct tive lenses. And that is, from the time I was pretty Young, I could make my sister laugh by deviating one eye in word, so not crossing my eyes, but moving when I inward. And then what happened was when I was in college and studying a lot, a lot and getting very fatigue.

I know I said 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 prism lent, which of course redirect the image.

But then I noticed that this I ball moving inward and I guess for those of you watching on youtube, not just listening um I can do this um by just moving one eye in right as I can move this I in so fairly pronounced I started to really drift in at a relaxation state and I started seeing double again so that wow prison, this one prison and lens is a crush of the story that I really don't want crush to the glasses but I broke them and and never went back to them. Um I have voluntary control over IT. But that's one example where the corrective lens can actually create a pretty significant shift in eye position if one realized on IT. So which this gets back to this issue of um when should people force themselves to work with their natural vision, maybe do some more far viewing as oppose and certain ly get outside and get sunlight into the sunlight, full spectrum light as opposed to relying on corrective lenses .

yeah and 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 eye ball, 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 youth straight.

And we talked about earlier at this possibility that you may have been having a little bit of inertial ent, eutropius or intermit and turning in of the eyes that then culminated on that day at day at the pool when you really noticed that um and your ongoing ability to actually turn one eye could be related to that. I remember as a kid standing in front of the mirror, I couldn't get my eyes to cross even though friends could do IT. And you know so, you know, I was in the losing .

group on that is very reassuring. I always worried when I go to a new dentist and then I look up at them in one moment and if they're not wearing a mass, that they're teeth or not. You Christine, I think, well, what am I doing here? So know an an open ologies with excEllent division brings me great comfort but callers.

children should have .

shoe right exactly um but yeah so so when to correct when not to correct with lenses and I realized here we have been talked at all about contacts. We've been talking about .

eye glasses yeah let's come to context in a sack if you want yeah let let me return to your question the difference between providing corrective lenses to allow you to focus for near or distance in your glasses so that you can go easy on the inside the eye. I mus having to work so hard, a lot of people get I drain and sort of headaches even from that from not having an adequate correction that they're wearing.

That's different actually, especially when where 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 straight and so that you have them both looking at the same point in space. And and there is actually quite a common treatment to try to do 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 to 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 are actually, I think, many optometrists who often specialized in in what are the right classes to give in a situation like that wherever possible, especially during a development as our bodies are developing, as we're sort of growing in our Younger years. Uh take the approach of intentionally trying to another correct not use a prism or not use a full prism correction uh and um to to really help uh sometimes it's also like an accommodative reflects that your eyes are just you're spending so much time reading at 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 uh 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 and kids just so they have to work quite so hard to turn their eyes and and sort of over exercised those muscles.

These are all great examples. We are going to an I care provider often for these kinds of issues. And optometry is the right first place to start.

You'd like to say that every optometrist and every automotive gist is, I is going to give the exact right thing for for each k or Young adult or other 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 imperfect science. And so IT could be that at least with, you know we're now twenty, twenty five, thirty years later but like I could be that today that twenty a year old version of yourself would have been given a different uh, approach to having one I imminently occasionally turning in like .

that is there any real value to um near far exercises you know so called pencil push PS or a smooth pursuit tracking? I've talked a little bit about IT before on the podcast, but that was not some time ago. so.

What are your thoughts on on that? Is there any value? Whatever means, they require a little bit of work, just like going to the gym.

But no, twenty five reps a day of near far, especially one is transitioning from each age fifty, is IT worthwhile. yeah. Is IT harmful and anyway.

definitely not harmful. And again, uh you know would IT slow down or sort of slow down your progression to b opa or needing those reading glasses? Uh could be some people also develop um sort of you know real failure to properly turn their eyes in. And so they actually would benefit if you've been diagnosed with that inability are having double vision near but not at distance um so that kind of convergence insufficiency, for example ah then pencil pushups off and get prescribed as a way to try to exercise those skills in you in your eye muscles.

I should interrupt here and just tell you for those who they are listening, not watching the pencil push up, we can put A A link to IT in the shower of captions was essentially taking a pen or pencil looking at IT at um at arms distance and then slowly moving IT toward 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 you will become blurry because I can't cross mize any further unless I become a psychology and then moving IT back out again and doing that for you attended twenty five repetitions maybe once or twice a day, a few times a week um that that's what those .

are pencil post PS yeah yeah so um you're certainly not going to heard 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 conclusion from sports or a follow you know, any any 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 move, follow that circle .

around me that, you know, just following .

a ball, you following any movement with smooth pursuit of your eyes, and after concussion, that actually those systems in our brain, the sort of reflects the ability to properly follow that, use that visual input, tell your eye muscles exactly where to move, gets disrupted, and so all of on your smooth pursuit starts to look choppy. It's not so smooth anymore, and it's actually a wait to diagnose and follow recovery from concussion. And part of the visual rehab bs, sort of neuro rehab, one of the approaches being used and and further studies still in recovery from concussion is actually doing those kinds of exercises like pencil push shops 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 like help regain uh the a tighter control of our eye movements and that eyes brain connection.

So if traumatic brain injury causes deficits in smooth pursuit, I move. And some of the recovery protocols for traumatic brain injury are to have people do smooth pursuit protocols and pencil pushups. Are these also the sorts of things that anyone can just do? I mean, whenever possible, we d like to share tools for various aspects of health on this podcast.

But of course, we don't want people coping this stuff in a way that could be detrimental to their, to the vision. So is that okay to get on youtube and finance smooth pursuit? um. Tool we can put a link to these there several of them um and people spend a few minutes doing this .

yeah you're definitely not gonna urt anything so totally find 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. Um I think most people would do them and not notice something in their daily life.

We actually have um made so much progress, you know in research, in thinking about how do we take the disease or this functioning or aging eye and get IT back to healthy and Normal. But there's a whole other area of science that we're really just barely touching. We've actually we've actually just opened a vision performance center to really get out, not just how do we we have the sick eye back to health, but what's the difference between functioning Normally a and functioning above Normal.

For example, athletes, when they get studied for visual 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, important questions that are really relevant to, you know, every regular person. Of course, you know, people doing e sports in the gaming communities and athlete s this 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 super Normal 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 black out your vision.

One thirty th of every second. Two thirty fifth of every second. Three third of every second.

Now imagine you and I are passing a baskett back and forth except you're wearing goggles and all the time you're only getting ninety percent of the data of where's that baskett ball on its wait of my hands. Now they're only getting eighty percent. Now you 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 information. And now I put you back on the basketball core without the goggles. But you might be really good 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, I think it's an amazing area and one that we've really just started to dig into.

and that's fantastic. So this is A A new program at stanford through the department of authority. Gy is IT linked up at all with the wood side 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 a lot. And and center, we we've long had really run through the department of our orthopedic, a human performance laboratory that's really you know much more about joints and muscles and strength and conditioning and stretching to layer onto 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 eight hundred versy student athletes and all the different sports at stanford.

And you might have a student athletes in and say, you know, something doesn't feel RAID. I got a little hit on the head. I feel like my vision is a little bit matter.

Maybe i've got a mild concussion. You could imagine doing some of these tests on some of these performance athletes, for example, and saying, well, gosh, you look Normal. But actually, they used to be Operating at a superNormal rate, and this is a noticeable decrement for them.

And so just starting to study and understand what's the difference between Normal and superNormal? 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 can be exciting and not just for athletes, for regular people.

You know, you talk about driving 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 well.

certainly there's physical training protocols which are redefining what a sixty year old or seventy year old could look like and feel like and be able to perform like a why not do the same for vision? Um so I don't think there's anything supernatural or a greedy about doing and I think that's the excitement of biology and neuroplasticity that you can extend IT forward as supposed to just trying to wire up correctly. Ly 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 twenty, twenty vision and a few of the variants so that any person could understand IT? So we think of twenty, twenty as perfect vision.

What does that mean? What would degraded vision look like, whatever those numbers are? And then what would above Normal, super Normal vision look like? yeah. And is IT true that fighter pilots have super noral vision?

yeah. That's another population like, like, like many athletes of people who may have sort of Better than Normal vision. Twenty, twenty. You know, we define almost everything we do based on, you know, kind of an average, not sick human being, adult, whatever. IT is right. And so twenty twenty vision means that you can read the smallest letters at twenty feet away, that the average healthy person can read at twenty feet away. So you can read at twenty what they can read IT twenty.

okay? Now if you have worse than twenty twenty vision, maybe you have twenty twenty five vision, twenty forty vision, maybe twenty two hundred vision, which on the eyes chart at the office is like the big e at the very top is twenty two hundred vision. That means you can read at twenty feet, what a Normal person could read at two hundred feet, right? So you've got pretty limited lower vision.

We can measure down to like twenty four hundred, twenty eight hundred at that point. We're getting into, my gosh, can account how many fingers are holding up, you know, that kind of thing. And then ultimately, we hand motion.

Can you have even tell if my hand is moving in this side of your vision or this side your vision? And then ultimately, after that light perception, can you tell if the room lights are honor off, right? That's kind of the edge of 啊， 并 fully blind， we call legal blindness, united states, typically twenty two hundred or worse.

And is IT true that there are people who are illegally blind that are out there driving. As we're having .

this conversation, I have to imagine that, that is unity in the case. But IT shouldn't be because those people obviously are really severely impaired and that's obviously quite dangerous. So, so, so that's twenty, twenty.

Now IT gets worse. Twenty four, twenty, eighty, twenty one hundred. Can I 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 a lastic surgery who are twenty fifteen, twenty ten.

If you're twenty ten, that means you can see a twenty feet, what the average person needs to be only ten 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 twenty twenty vision.

Does the degree of visual acuity, because that's really what we're talking about here, differ dramatically between the two eyes in .

most healthy people know you know remember we talked about you're born with something like twenty two hundred vision takes you a couple of years and there could be a little bit a metro .

twenty two hundred vision. Yeah, this reminds me, i've seen images of what babies can see. Your parents love looking at their child and thinking that their child is looking right back at them.

And indeed, off in the child is looking right back at them. And your face to your child start to break this two folks is incredible bly blurry, even at that close distance for probably the first sixty eight months events. Before you come into sharp relief, they're not seeing the fine details of your face.

yeah. So smile big.

Keep I and keep cooling at them because they can hear pretty well, yeah, the objects of newborn babies are just red, fully bad, but they need visuals.

Now, other species, not, you know, hawks, are actors, holes that hunt. They can naturally have twenty, ten, twenty eight vision rights, a 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 twenty twenty 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 at 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 what's a twenty, twenty and most people, right? But it's it's Normal, have that slope off and our visual acuity, your ability to read the eyes chart on the edges of your vision if you can read the big e that's pretty Normal like you will be twenty two hundred out on the edges of your vision and we would feel like, yeah that's pretty Normal. Um so so our highest security visions in the center.

And that's a big part of why we spend a lot of time using those. I immutable les, to look around, right? Got to get a above high acuity view of what's around us. Uh, fill in, fill in the gaps of what are what our brain is, is interpreting our peripheral world to look like.

Almost like we have two visual systems. We have a high active, high pixel density camera in the middle. And then surrounding that is a pretty low resolution, but very fast detective camera.

Yes, yes.

you mention lactic, but I want to make sure that before we talk about lactic, that we talk a little bit to our 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 I think we should level necessarily exactly like our ancestors, but it's a pretty bizarre adaptation.

To put a lens directly onto the front of the eye. You have to imagine that the cells and to shoes, there are a customer to getting a certain amount of oxygen. There's customer getting a certain amount of interaction with the environment and and you also now adding another surface the way that the tears are going to interact with the um you know with the corny of the eye or probably changed. And who knows, maybe IT doesn't make any negative difference at all but yeah putting your contact lens on the front of the eyes you know about as close to putting a device on your brain as I can think of except for maybe the .

nuclear um implant yeah yeah it's a great question. Now first of all um I wanted distinguish uh there are a few really medical uses for different kinds of contact lands like scarrow 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 a change the tear dynamics on the surface of your eye.

They um they decreased the oxygen, you know diffusion that's just sort of out in the air onto the surface of our eye, onto the cells that are on the surface of our I but most of us, especially as we're Younger, have enough tear film, enough oxygen reserve that we can easily tolerate these polymer jail soft contact lenses and and wear them happily. The advantage of contact lenses over glasses, purely from the perspective of correcting your vision, is that there is different elements of of of of the shape of your eye that need to be corrected if you need corrective lenses. And so, for example, if you are, 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 a stigmatism. That's where, instead of having a basketball shaped eye, you have a slightly football shaped eyes, not round in the same dimensions on both aces.

And again, glasses can correct that. But then there's higher order abortions in our corneas and the clear window in the front of the our eyes or or to some degree in the lens inside the eye that are focusing the light that the glasses prescription can 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 their contact lens correction, then 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 context could work for you. Now there's another element though and that's like cautious.

There are risk of contact Lances and especially as we age um we have less tear film reserves. The 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 fungi as, and if you get a corneal infection from a contact lens, IT actually can be quite devastating to your cornea.

Even if you successful ly treat the infection, you can be left with some corneal scaring. Thankfully, this happens very rarely. But when IT does happen, IT can be quite difficult, you know, on the person there after the sort of suffer through having maybe a scar from that infection on the surface of the cornea that that leads to some blurry vision, for example. So we always recommend that if you're going to wear contacts, that you'd be really attentive to whether you're tolerating them well, and then are also to be really attentive to the recommended use and cleaning of the contact lenses. I actually recommend that even though there are 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 or use for, you know, two weeks or four week period.

So these are disposable contact.

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 lens 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 them overnight.

Because overnight, when your islands are closed, of course, now you're getting even less oxygen to the surface of your actually most bacteria, especially many of the infectious bacteria, to our bodies and to the surface of our are actually bacteria that don't really like oxygen. And so we've got a low risk of getting bacteria infections on the surface of ri. But if we use contacts too much, don't clean them or sleep in them overnight when our islands are closing.

And as even less oxygen kind of helping keep the surface more, more clean, if you will, uh, that increases the risk a lot. So being really good with the recommended use and cleaning of the context is critical. Considering daily use context, you don't have to.

And look, most contacts are going to be the two week or four week kind put him in the cleaning solution over night each time, given a good race, and put him back in the next day that I can. Most people, nine, nine point nine, nine, seven percent of people are gonna. Do just fine with that, follow the instructions and never get into trouble.

As we age, they're gonna become less tolerable people gonna. I used to wear my context for twelve hours. Now my eyes felt really dry after six or eight or ten hours, maybe some years after that, they say, gosh, I A barely is IT for four hours.

Use them when I go out on a saturday night, uh and and that's okay. You can you can back off as you need to back off. But in the meantime, if that helps you, especially in the Younger decades, that helps you really enjoy your best vision. great.

What about U V protection in eyeglass lenses and your contacts? Um 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 great lights of any wave late late at night. If you want your milestones production to be Normal and you want to sleep well. Doesn't matter if you're wearing blue lockers or not, if you're just under blazingly right lights, it's gonna ress your military ona.

And yet some people enjoy blue blockers for that reason nowaday a lot of people wear blue blocker glasses, are 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 sucking rythm. 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? And I said, i'm perfectly happy to be wrong and revised my my stand on this um yeah what do you think about this U V A B blocking yeah it's .

it's really important to distinguish that U, V, light on the light spectrum is right next to blue light. Red lights on the other end, of course, inferred is beyond that. And our eyes, other animals can see these, but our eyes can see in for red.

That's why we call IT beyond red. And we can see ultra Violet. We call IT beyond Violet.

Uv light is right next to blue light. U, V. Light is known to have a lot of adverse effects. It's not really good for our skin and therefore, you know we were really want to avoid sunburn and uv 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 terms of like kind of how dry or heritable your eyes might feel for some people. And certainly over the long term, U, V, light will accelerate the formation of cataract, which is a blurry of an ox date of glory of the lens inside the eye. Profound U V light can be damaging the retina if you're getting wait too much on the inside.

Um so uh so block and 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 lens is also filter at least U V light. Now blue blocker, blue blocking glasses is 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 a plastics. But I think almost all of them now filter the U. V light, which again is like probably the safe move for our eyes and paraos lar environment around the eye environment.

Um oh, blue blockers, you know, that's been a huge fan, i'll tell you of the last three years through the pandemic, everybody getting on their computer hours in front of zoom meetings where we used to walk for building the building for a meeting, things like that. You know I remember you know like this sort of big optic in these kinds of questions. And i'm not sure that there is any data that blocking blue is helpful in anyway.

And as you say, IT may actually play into a sort of circadian entrainment of our natural daily retha. So I think blocking uv is a good idea, and I think it's pretty standard. Um you know they make glasses, by the way, that actually react to U V light.

They are called transitions or maybe a few different brands, I don't know, but but you know these are the sunglasses that are clear except that they turn dark if you're out in the sunlight and it's not just any sunlight, is actually the uv wavelength that that caused the chemical reaction in the glasses to turn from from clear sea through to to sun glass blocked glasses. And um 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 sung glasses even though it's Sunny out. And again, that's because all standard car glass also filters U V.

That's why if you're riding around in the car, it's Sunny out, you ve got your hand, you know up next to the window wearing A T shirt. You've never get a sunburn through the car window anymore because all our car glass is also filtering U, V light for us. So so that's a .

very informative answer. And before we started recording you, I were discussing this practice of morning sunlight viewing, which can a highly record over and over. And you pointed out that low solar ring of sunlight, sunlight low in the sky, viewed for IT, be ten minutes a morning.

And again, not forcing oneself to look at IT and stare, but blinking as needed is not going to cause this extensive U. V. 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 lens ses and therefore are not blocking uv light to the eyes, what should they do or they in trouble? Should they be wearing a brim hat?

Brian has a great idea that i'll get a rid of a lot of the direct light into the eye. Of course, you're still have reflected light off of surfaces and that that can include U V. Light, of course.

Um you know wearing sunglasses outside, even if you don't have corrective lenses, you know it's may also to be more comfortable to wear sunglasses outside. Um so so these are all fine. You know at the end of the day, probably not making a huge difference in the health of your eye, whether you've spent the last fifty years wearing sun glasses really dogmatically for your outdoor time or not.

You know, if you are going to develop, let's just say, age related cataracts inside your eyes, which we'll all get. Cat, if we all live to one hundred and twenty, we all get cateract. You know, it's it's onna happen.

Some people Younger, some people there. Maybe if you are really dogmatic about wearing your U V blocking sunglasses, as maybe you'd get your your catacomb seventy five years old instead of seventy two years old, that may not be a huge difference in that regard. Um so again, not something to be super stress.

I think 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 brain hat is is keeping sun off of your face and these are the you know some of especially the upturn portions of your face， like the cheeks and the nose. 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 White brain APP is is helping you for that as well.

can help but ask about comfort at varying levels of brightness.

I'm the person that when sitting in a cafe or something in on a bright day, I can be directly across from somebody like you who seems to be perfectly fine without sungars ses, and maybe you were shaded under an umbrella or something that, and i'm squinting like crazy, is IT Normal for there to be a pretty 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 study, but I will tell you, like I have the same impression you do, which is that if you have a blue eyes or light color eyes, that you are more likely to have more sensitivity. We know that there's differences in the irs muscles that construct and dilate in response to light.

For example, when you go into your eye care provider and we're going to do a dilates exam and they put the eye drops in your eye that dilates the eyes, they sort of changed the the the nerve in pulses onto the irs muscles of the irs dilates and you get this big, big, open the eyes um people with blue eyes, we absolutely know blue or haze or light color eyes uh you put that eyedrops to dilate the ize it's going to last four, six, eight hours. Where's an a Brown night person? Often the dillaway only last one to four hours so there is clearly biological differences between the irises and their muscles and maybe the nerves that feed those muscles between light IDE people and and darker IDE people uh 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 right light as effectively, you're gonna find that bright light more frustrating, more annoying ah you know even painful people feel like their eyes are cramping almost uh as they try to get that those eye muscles to activate to bring down the pupil and block some of that access light from getting in .

interesting go back to lay sic. What is lasik and should I get lasik? I surgery does does everyone need laca can help. What can I make us super physiological? You know, can I make me at twenty ten?

You know, often IT can. I'll just say that, you know, right up front, that is amazing. People will come out of basic surgery a Better than twenty twenty. But the cornea we talked about before, that's the clear window on the front of your eye, although light us to get through there.

And we talked about before already, like if your cornea is misshapen, if the basketball shape of IT is to to shallow or too steep, then you're gona need glasses to see a distance. And also at near, if it's too football instead of basketball, then it's going to be what we call a stigmata m and and then you can you need a correction for that instead of correcting with glasses that sort of help shaped the light. So I can go through your slightly off shaped cornea instead of our in contact lenses, which also shaped the light just as it's entering your corney right on the surface of the eye.

You can just reshape the corner. And the way lassi c does that, there's a few different versions of lasik. Uh but the basically the way the plastic does that is IT actually a blade or uh uh a gets rid of a little ring or rm 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, a lays laser c you know, starts with the word laser.

If you've got rid of that edge tissue, then you're sort of making you a little more basketball shaped, right? Or if you were too steep on your cornea. And you use the ways or you're going to shave off a little bit of the the tip of that basketball, right? Then you're flatt entering IT out, flattening out the cornea.

So if that kind of reshaping and the technology has comes so far that the basic procedures can actually correct, not just the regular aberrations that we talked about, but also some of these higher order abortions. And there are different monikers for this kind of laser at all, I think, become fairly standard, but wave front 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 eye to make that corona pass the light as ideally as possible. Now, one or a few percent of patients will actually have a dry eye problem. So after a place, because though IT does interfere a little bit with those corneal nerves or example, and I and I do think that if you're a person who already has dry ee, hopefully if you're asking your eyes surgeon about this, hopefully you're being cancelled, 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. Um but for a lot of people, especially a lot of Younger people, it's quite common.

I I think the statistics are just maybe fifteen or twenty percent of people who would benefit from laser you know who would otherwise be wearing glasses may get lasik at some point in their life and um you know I used to joke you know waste IT cost more money than a pair of glasses, but IT doesn't cost more money than ten pairs of prescription glasses over the course of a decade or two, you know and so I used to joke that gossip, uh, if everyone had to have laser eye surgery for the best vision and someone came along and said, hey, i've gotten an invention you don't have have laser eye surgery anymore IT rests on the ears in the bridge of your nose I call them glasses could they have sold us 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 work glasses and i'd love to be able to walk around without relying on glasses or contacts. Of course, people are very athletic, spending a lot of that their time doing athletic.

They may be quite irritated to have to deal with glasses or contacts, people who have very severe prescriptions. I mean, if you wake up and you can even, really, you know, we are fumbling for your glasses on the bedside table because you have such a scat strong a prescription, you can even see what he 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 laser. And in, I don't know, ninety nine percent of the time, it's gonna like a safe, comfortable outcome for the patient.

Do they do licit on kids?

Um there are certain conditions, unusual corneal conditions were see like classic that use. But I believe a it's ideal to not do IT on children are 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 and therefore the prescription you need.

And therefore, what exactly the classic with laser while you're still in those growing years and you really want to be to say, hey, my eye glasses prescription has not changed in the last two or three or five years because if you are, do lasik and then your eye keeps changing shape, then by the next year, all of us on the laces s not do you're backing glasses again, right? You can do a touch up lick, 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 twins where your eye has stopped changing its pressure every year. You've been steady and stable for some years, and now you do the lsc. And I could easily last you a decade.

You mention dry eye, 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 ye.

And I thought, dry ye like of all things, like, why dry? And the more I learned about IT and realized that there are millions and millions of people that really suffer from dry eye, and for whom standard drops are just not working. So what undersized dry eye is IT some deficiency in the lack of one glands that produce tears for the iron and I think of tears are just kind of sault water um and I wonder if they are more than that, is there are an oil in there and if we know what's in tears, why can't somebody just manufactured something .

that works as well as tears? Yeah you know, IT turns out we've got a lot of other eye diseases, but by far the most common I disease and and i've been told by far the most common I treatment, you know, purchased by anyone. Now granted, it's almost as over the counter things like artificial tears is for dry I and uh in part that's because as we age, our teer quantity goes down and our teer quality goes down.

And so what are those do you mean? We have two different major elements to tears. And as you alluded to, one is the salt water part of part of the tears.

And those are made primarily by the lack of oglander. There's a steady drip of those tears onto ocular surface as well as reflective tearing, right? If you get an iou h in your eye or you cry your your lack of grand action, squeeze out extra salt water tears, uh, until the surface of the eye.

And so so that's that's where most of the so a wet part is coming from. But there's also essential oils, critical oils. These come from other types of glands, including glands. And our islands called my booming and gLance, and the oils form a surface over the salt water part of the tear film, and, 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 tears, but also the quality, and in particular, the oil parts, I can often be seen to be going down more quickly. The the eyes drop industry has pretty much solved for replacing the salt water part of your tears, right? You can get either bottles of pressure preserve of containing, you know, you can use that bottle all month for a month or two, or you can buy these strips of preservation free artificial tears, which are really basically like the salt water component.

And you can use those preserve of free ones. We have patients using them every hour. If they need to, you're gonna hurt anything with preserved of free artificial tears.

You just drop them in. Just drop them in. Yeah, either eyes is as often as you want to need when you feel IT. It's exacerbated in the world we live in, uh, especially these days now with more time on computer IT.

Turns out that when you read, including when we maybe used to read more books than we do now, but also read on the computer, stare at the computer screen or work on the computer or actually just even watch the TV. thanks. Very careful studies.

You have blink less when you're doing any of those activities. And when you blink less, less, you're redistributing the tears less effectively and you are squeeze out less of the tears, including less of the oil as effectively as you could be when you're blinking. And so um so between aging, teer, quality equality, a lot of our activities, uh, we're kind of in this losing proposition now.

Now I mentioned that um we're pretty good at replacing the wet, salty part of our tears, but actually is an industry we haven't really figured out a how to really effectively replace the oilily 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 like kind of working against the salt water part of our tears.

So yeah as an industry， as a as a community, uh that we haven't really figured out how to get the oil parts of far either by effectively replacing the oils or treating our islands in a way kind of rejuvenating those oil oil glands, getting them kind of go back to their youthful state again, you know so the eyes, including the islands and the oil glens, unfortunately, they are aging just like the rest of our body. So so this is this is one of the major features, uh, is, uh, is dry eye. And and, uh and it's tough on patients because you feel IT really tough because you feel that .

I have yet another experience to report where when I had the black for itis, which fortunately was transient ent, I also experienced that every time I blink I could feel the blank. And boy, i'll tell you, we all, most of us, take for granted what pleasure is to not observe the blinking of our eyes. Because for those, I think that's about two weeks.

Every time I blink, i'd feel an almost sandpaper like the experience. IT wasn't particularly painful, but I was very uncomfortable because suddenly conscious of every blink, and it's very distracting. Now that resolved when the black verities resolved, but I can't even imagine what I we'd like to deal with that all day long, every day. The only 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 ee IT can be managed with just the regular over the counter artificial tear drops, you can buy the grocery store over the counter at the pharmacy for a subset of people who have really much more severe symptoms with a dry I it's really it's hard, it's a really hard thing after to live with all the time and and we cancel on the use of tears, we council on the use of I like cleaning, like we talked about before.

We take either these island scrubs or a little dilute baby shampoo to keep those eyelash is really clean that keeps those oil glands functioning at their top capacity for you so that you're maximizing, you know, high quality your production. Reducing inflation tion is also important, whether that inflation tion from allergy, of course, a lot of people's dry eye gets much worse. In the spring with seasonal allergies when call in is around if you have dust allergies in your home, uh h that worse ince your symptomatic dry I uh or other forms of information.

There's there's an element of dry ye that we actually think is inflation tion kind of working against our tear gLance and and in fact, some of the prescription drops now to help combat more severe dry eye, uh our anti inflammatory or even load those steroid types of eyedrops. Um so I think these are all uh sort of next generation treatments. I think the at the really leading edge of next generation treatment is trying to Better understand the nerves on the coroner and ocular surface and if there are ways that we could Better treat them and help help regenerate and rejuvenate 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, uh, either, for example, blood serum. Your blood serum is actually very rich and growth factors. And many of those growth factors that turns out empirically are really helpful for people with dry eye. So if you are one of those people who's been really struggling with with dry eyes, you might ask your, I care provider, hey, I heard about serum tears. Is that something that .

could help me see tears? So this P. R, P, is this plate that rich, a .

related, but not the right place, rich portion, at least not yet. They can draw your blood, spin out all the cells, your 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 preservative. In some cases, you can keep IT in your freeze, thought the bottle, when you're ready to use IT, you know, each few weeks and and then use IT, just like an I dropper bottle. And those serum tears actually can be very helpful for people with with much more advanced or severe hard to control dry eyes symptoms.

Uh, companies are really trying to figure out, hey, what are the most important parts of the the serum? Can we just identify and package just the growth factor and uh and turn that into a product for dry patients. And so there's a lot of research on the ocular surface and dry ee um going into um going into that space right now.

I'll tell you the one of the recommendation that I always give patients, there's a fair amount of evidence that if you're getting too much of some of these preservation chemicals, uh, which of course, if you're going to use an eyedrops bottle for a month, IT should have a preservation in IT, right, so that you know open the bottle and then IT grows bacteria a couple weeks later and now you're you know you're using contaminated eyedrops. Uh, so for bottles it's typical of preservative. But I really recommend for patients if they're using anything more than a couple drops here and there.

H for their dry eye control to actually go for one of the preservation free artificial tears. They come in lots of great brands. I'm sure the house brands that at any of the pharmacies use them to and make them to.

And these are the ones that come in like strips, plastic strips. And you break one off. You break off the little cap. You can use as much as you want all day. You have to throw that one out. If you have anything left, ed over have to throw IT out at the end of the night and the next day, break off a new one because there's no preservative.

And once you open IT, you don't want bacteria to grow in that salt water, right um but it's really good because the preserve tips 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 drop or to upgrade cost a little bit more money, they're still over the counter. Upgrade yourself to the preservative free artificial tears.

Those are great recommendations and also really interested in this system thing because you know where this discussion taking place ten years ago and I raise P R, P plate rich plasma, there will probably be a lot of arrows, no unintended.

Because I think myself and a lot of other people in the it's called the sort standard scientific and medical community looked at plate rich plasma right alongside stem stell therapies because they were cheap to jail. Back then, as you were called before, the a regulations about stem cell claims, which we will get to, of course, P R P, was suggested as a source of stem cells IT. Turns out there very few, if any, true stem cells in P R P.

And yet now as I understand IT P R P is an F D A approved protocol for injection into uh the uti st injection into pretty much every tissue and organ system of the body order to quote, to rejuvenate IT. And here i'm not promoting P R P. And yet IT is a very common practice now in more standard medical clinics.

But I started off kind of niche, even grain market kind of underground. It's diverged from stem cell therapies. And we're gone 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 patient eyes to recover vision and actually blinded them. So we will talk about stem cl therapies, but for the record, is P, R, P, something that now standard in major open ic clinics? Excuse me, including your department at stanford, are you drawing out blood spinning IT down, taking plasma, taking serum and reinjecting IT or reapplying .

IT to patient cy eyes? Not not yet in automotive gy in eyeliner S I, I would say we're sort of like right now on the edge of a groups are starting to study that is IT safe, is IT valuable. Is that any Better for certain conditions like on the ocular surface, then see tears, for example, this sort of diluting patients own blood serum.

Uh, so so it's being studied is a very active area. No IT turns out that this prp h plasma has a you know again, like a high concentration of growth factors. That's probably what's responsible for a lot of the kind of quote, tissue rejuvenating ation effects be be there as they may.

But but it's being study, but it's definitely not a standard of Carrier, at least in in open ology space. And and you know I think whenever ver, 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 tested carefully in a few people, maybe a few of the most severely affected, affected patients.

Be really thoughtful about, you know, the effects of trying out for safety. Then as you develop a little understanding of the safety, you really, we want to eventually get to properly controlled. Randy zed, what people in the community often called double .

blind trials, but we are an .

optimistic like to call double mass trials s really want properly controlled trials testing. Is that really working? Is that really deserve the claims that people are making? And that has not yet really come to fruition at that level for open ology or eye Carry yet.

So we've been talking a lot about Normal visual development, eye e 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 glow coma, things like retina test, 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.

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 the 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 an adult od? 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 gonna differ where you are in the world.

But the major, the number one cause of low vision is actually reflective people who need glasses, and especially in other countries, affordability access can even get glasses. Okay, so that's just refractive error, but that's fundamental correctable. The next most common cause of vision loss is cateract cat act is the blurry, the aging of the lens inside the eye.

Behind the korea, we talked about how that is responsible for focusing light under the back. The eyes also also be clear enough that the light gets through the ends. And uh, cataract is a Normal aging process.

You know, as I said, if we all live to one hundred or one hundred ten years old, will all get cataracts, will all need cataract. We actually in in the eye clinic, we see cat ax years or even decades before they're affecting your vision in a meaningful. So the cat acts are forming and that's okay.

But at some point they get bad enough that it's time to take them out. We've ve actually solved for cat act surgery pretty efficiently, and we can do a four to eight minute surgery. Maybe if we're taking our time, it's ten or twelve minutes of surgical time.

Take out a cat act. IT works beautifully, ninety nine point something percent of the time. We put a plastic, clear plastic lens inside the I exactly where euro lengths used to be.

And there is even lenses that can flags or focus light from far and near. So carriage is, fundamentally, there is still room for improvement, but there is fundamentally a solved problem. Uh, the problem is, is that worldwide, there aren't enough cataracts surgeons, there's not access to care.

The machinery or the lens is um cost too much money in developing countries to get out to the number of people who would need them. So it's actually just again, and access to care cater actors, 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 programming around global options. Ology global eyes care to solve for cataract act, just to bring that solution, two 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 glow coma. So what is got a goal is actually probably a little cluster or conStellation of diseases that we laughed together. It's a degeneration disease like a nerd generation.

We talk about nerd generations in the brain, like alzheimer and parkinsons. Glogova is a nerd general disease. IT happens instead of affecting one or different area.

And rain IT happens to affect the object nerve that connects the eye of the brain. And we need our optic nerves Carry all the visual information. From the eye of the brain.

And so if your optic nerve is degenerating in glow coma, and I should have the other optic neuropathy ah so called diseases of optic nerve degeneration. For example, you can get a stroke of the optic nerve. You can have an inflammatory diseases.

Light multiple schools is called optic narratives that affects the optic nerve, so you can get other optic nerve diseases, but all comes by far the most common optic neopa. Thy and the promise 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 written in the optic nerve, that's the central nervous system.

And there's no regeneration. And that's why spinal court injury leads to permanent paralysis. While optic nerve injury or optic nerve degeneration, unfortunately, we need a permanent vision loss.

So in the case of glow homa, how do we get ahead of that? Glow coma has two major risk factors. One is increasing age. There are actually infantile and pediatric comas, unfortunately. And those can be much more aggressive, much more damaging when they so early, and kids and babies.

And in shouders, most of the kind of run of the mill glad coma usually pressured presents in adult, and even in in the aging adult. So much more common after fifty or sixty, seventy years old, increasing. The other main rest factor for gloomy 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 high pressure to keep our eyes as as an inflated balloon. But if the high pressure goes too high, and we talked about this power, you won't even feel IT if IT slowly gets too high.

If the high pressure goes too high, that causes glow coma and um and that's one of the things that we talked about you really include in a comprehensive I exam when you're just getting a screening check up at your eye care provider, at your automated or author logic office, they're gone to check your pressure. And just as a screening tool l checked mature, it's not too high. We can treat glow coma today by trying to reduce the impact of that high pressure by lowering the high pressure.

So we have treatments for gala that target the high pressure. We have medications like eyedrops. 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 flew IT 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 kouka ends up being the number one cause of reversible blindness in the world is, number one, we can't get those therapies everywhere in the world. The affordability of eyedrops, the access to lasers or surgical procedures around the world isn't equal to what IT is here.

And even within our country, you know, people may not be accessing health care effectively to get screen for glow como treated for goa. The other big problem with cocoa is that IT affects our perform vision first and only very late in the disease. As IT pinch in and finally pinch off, the center of our vision in typical glow comes.

And that's a real problem because we don't notice if our preferable vision is down, you know, our profile 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 preferable vision is fine. But actually your profile vision could already start being damaged by gloomy.

And you won't notice IT in regular daily life. And that's where the importance of screening and early detection really come in for glow coma, what we don't have for globe. And we can come back to, I kind of what's the cutting edge of the future in these eye diseases, what we don't have, our treatments that really target the optic nerve of the general process and h, we can come back and talk about that.

So that's about command optic neuroses than the next two major causes of currently largely irreversible vision loss, our age related macular to generation and then diabetic retina pathy. Now age related macular generation is just like that sounds major risk tory's age. It's very common.

And actually in the developed world, countries that are more developed, also countries that have a larger occasion White population is more common in certain population than in others. Um IT actually is you know definitely a leading cause of vision loss in the elderly population, for example, in the united states. Um and ah there's two forms of mac 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 roads.

Do your low light vision at primarily your comes to color vision and bright light, you know sort of Normal lighting that we experience you know through most of our awake die. And in that back of the retina, you can have what's called dry macia generation, which is a slow, thankfully slow, but slow in cyst disease that causes the degeneration of the roads and cons, and also the support cells that help feed the roads and cons and take care of the roads and cons. They're called R P E cells, retina pigment, empathetic.

It's not really critical, of course, the names of every different cell type, but these are like the, the, the light collecting cells in our eyes, in the rattle. And they degenerate in macular to generation. And in the dry form, there's the slow to generation.

But some percent of people with the dry form macular generation will actually convert to what's called the wet form. It's called wet, because new blood vessels actually grow inappropriately under and even into the retina. And new blood vessels, unlike ARM mature blood vessels, tend to be leaky.

And so that the flew at, leaks out of those blood vessels gets into the retina, interference with vision. And that can lead to a much more acute loss of vision. Now we have some treatments for wet maculated generation.

We have injections that can go into the eye that actually fight against the molecules that are causing those new blood vessels to grow. And these are antibodies that can be injected in the eyes, and they can be very effective controlling patients, wet macco to generation. It's been a much bigger appeal battle even of the last decade of as advances are being made to really try to knock back or or or slow down even the dry form of magnetic generation.

There is just an exciting news, even just in the last few months, the first uh, successful trials of a treatment for the dry form have just shown success and properly randomized controlled human clinical trials faced three 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. Uh, maybe by twenty or twenty five percent. So so patients are still gonna worse even with those treatments. So they're still a lot more to be done to really knock back macular generation.

I want to mention you mention retina test pigmentosa, that's like an inherited form of a type of maco generation is also affecting the rods and cones and also the support cells, the R P E cells in the back. I red, nice. Pigmentosa is an inherited form. There are actually many different genes you could have that could leave to retaliate. Pig, pig tosa.

In aggregate, if you add up all the people with all those different genes, uh and and I can be very devastating because you can really affect the vision, knock out your vision very early in life, including in children and even versions of that and babies. But yet that all up, it's still much less common and aggregate the macao to generation. 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 clump those together, macker generation, retina tied pigmentosa degeneration of the roads and cons and the support cells, the R P E support cells.

And then you you can't have this part of the discussion about water, the devastating eye diseases, without bring up diabetic retina p, but especially because diabetes, unfortunately really continues to grow in, especially, let's say, in the united states, certainly in the developed world you know as we um especially type two diabetes with eating habits, exercise habits contributing to a proliferation of some of the risk factors for type two diabetes, meta lic syndrome, obesity um we're unfortunately seeing a proliferation of growth in the number of people with diabetes and with the growth and diabetes unfortunately comes the 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 retina p but they are and there again some of the same damage that occurs, especially when in diabetes against some new blood vessels are growing or blood vessels ls 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 to generation um but they're still a lot of vision loss with diabetes and diabetic retina. P 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 your at least annual exam with an eye care provider or having someone take a photograph of the inside of your eye and rate that photograms to say if you have any diabetic rats up with you or not.

In terms of interventions, can we talk about diabetic retinopathy first? Because course type one diabetes is is a failure to produce and so on, relatively rare compared to type two diabetes, which as you mentioned, is proliferating in developing countries, right? This is probably unprecedented in the sense that developing countries have Better medical care typically than non developed countries.

Um more opportunities for food nourishment. And yet it's clearly a problem of nursin inlay insensitivity. Obesity at sea is this type of diabetic written apathy that one observes the same for type one diabetics versus type two diabetic because my understanding is type two diabetes this instant insensitivity is a bit of a continuum, right?

I mean, the type one, I, as far as I know, is all or none either make insulin or you don't, but type to diabate. Someone could be mildly in issuing insensitive or severely insulin sensitive. And sometimes i'm told people are not necessarily obese and can have time to diabetes as well. Certainly things like smoking and alcohol and take can contribute to that. So how equivalent are type one and type of diabetes when framed under the umbrella of diabetic rat apathy?

Yeah, the the time to presentation can be different. Uh, a type one diabetic usually presents what sort of catalyst mic sudden loss, sudden sort of final loss of their ability to make instant IT usually presents in childhood and teenage years, but can present you can have laid on set type one diabetes. Because it's kind of a sudden presentation IT can take some years after that to show any diabetic retinal apathy.

Whereas just because just like you said, type two diabetes can be on a continue and people can have like kind of a mile type two diabetes, but you know get along, you know gone through life kind maybe not even realizing you know at first and so when your diagnosed with type two diabetes, you've probably had some insulin resistance for the year's prior to your diagnosis. And so in that case, you often can have um you know like you you're at higher risk for presenting sooner with the the complications of diabetes like diabetic c ret noa thy now given that the actual retina pathy is very similar, maybe the same between type one diabetes and type two diabetes and again, IT involves things like leaky blood vessels, new blood vessel growth. There are some amount of nerd generate this function that just simply occurs. Uh so so uh you can have little little hair ages or bleeding spots in the retina, tiny little strokes or microvascular events in the retina. Ah so that can happen in either type one or type two diabetes once you start having the retinopathy IT does like pretty similar.

So what can people do to prevent or treat diabetic retina? But the obviously the type one diabetics needs to take inso in in order to survive really tech two diabetes ics need to get their obesity under control if they are in factories and get their blood shooter levels under control regardless. That's my understanding. And by extension, are you seeing any reductions in diabetic retina pathy with people that are taking these google unlike peptide myrick um like oei c which is used to treat type two diabetes.

Yeah it's been a very exciting development for the diabetes field, this new class of of of the anti diabetic drugs. And um so uh there you've touched on a couple of them. There are a few key things uh for reducing the risk of diabetes or the impact of diabetes on your retina at the risk of debet rt nop at the um or impact of diabetes on your retina.

One is, as I mentioned, get regular exams, be screened. You know any diabetic should be screamed at least once a year with a, with a good comprehensive retinal exam. Looking for any of these items.

The number one most important element to prevent diabetic rat, nope, thy is to control your diabetes and having a real good blood sugar control, keeping your hemoglobin a one c which is one of the blood tsi c gets used to measure how your kind of long term diabetes management is going. Uh that's really um you know first and foremost the most important and that's been shown in large clinical trials. They actually random ze patients to hate take care of diabetes or do our real good job taking care of your diabetes.

And the patients who do are real good job taking care of their diabetes have much less diabetics. Ret note. 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 two diabetics, especially if you're catching them early, can be improved with some of these so called lifestyle changes, like improving eating, watching what your food intake is, you know, getting good exercise, trying to lose weight. Uh, so these are definitely on that list of how do you get to good blood sugar and blood pressure control.

But service is 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 c ret oaths is detected and blood sugar and 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 you're redness, getting you kind of key blood vessels from diabetes are there are treatments that we can give the ice specifically to try to counter the diabetic gretton up as a horrific .

in terms of glove coma, as you mentioned, gloomy is related to pressure, although there is pressure Normal.

gala gala ma is a .

death of the retina gangland cells, the neurons that connect the eye to the brain. And once they are gone, at least at this point in human history, they can be replaced. But hopefully, because of work that you've done and the other laboratories are doing at some point, that statement I just made will not be true and the rgc can be replaced. Meanwhile, what can and should people do to find out if they have long coma and to treat alcala? And is IT true that even if somebody has Normal pressure, that lowering the high pressure further protect them against coloma?

Yeah, that's absolutely right. So most important to get screamed with a formal exam at your optometrist or opened ologies because you you won't notice, you won't have any symptoms. If your eye pressure is too high, you will not you're not likely to notice until very late in the disease if your peripheral vision is being damaged through the course of gloves.

A so most important to have a screening exam, a good comprehension screen exam will always include checking the eye pressures and also looking in the back of your eye. The head of the optic nerve or all the fibers leave the eye and Carry the optic nerve information back to the brain. We can see that when we look inside ji and and and gloomy has a fairly characteristic look to IT in the optic nerve ahead.

So so looking at the optic nerve, had a we have imaging and profile vision testing that can also be included in the screening exams. So if you really get a comprehend of screening exam, you can very reliably detect if you have glow comment to worry about or you're in the clear if you have to comment 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 ta 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 benie, non invasive aser. It's not the same kind of laser that is used for a lay sic, but there's a benie very safe type of laser called selective laser turba ua plate S L T we call IT. And that's also very effective as a first line actually in the largest clinical trial, uh, from which the data have been coming out just even over the last few years.

It's called the light trial. Uh in the light trial, patients with calmer Randy assigned to either get the laser or the sort of most common first strongest eye drop and uh ah that gets used clinically and actually on many features. They both work at least as well. But when looking out over the long term, actually the laser had some advantages over the eyedrops, not the list of which by the way, is very nice for patients to not after like remember to use the eyedrops every night.

And so so that's quite helpful, I think, uh, to keep in mind as a treatment option, uh, early in the course of the disease, of course, if the eyedrops under lasers are not enough early in the disease, we also have surgical approaches till lower the high pressure further. You know, even with all of our treatments, all of these treatments stepping patients through all of this, about ten, fifteen, even twenty 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 goma um including in you know quote on quote developed countries uh there is still a very significant cold of patients that go blind, a legally blind and then you absolute blindness, I can even tell the lights are on in the room.

Uh, so it's devastating. It's in cda. It's hard to detect early. Um uh, so glad is still a tough one even with all of the treatments that we have.

So get your pressures checked folks. And if you are prescribed drops, take your drops. I hear about patients not taking their jobs, which to me just seems like baffling. But I guess having to do something day in and day out is can be trouble some enough that unless people are losing their vision very quickly, or they are very afraid of losing their visions, sometimes they just neglect to take them.

It's hard. It's hard for glaucoma eyedrops. It's hard for taking your blood pressure medication. It's hard for a lot of medicine.

You know if if you're taking a medicine where you don't feel Better, you know you have a headache and you take an aspirin or thailand, all our and I be proof and uh, you know you feel Better, you feel reinforce scotch taking that till mid sense, right? But if you're using an eyedrops that like, hey, it's gonna protect you for the next twenty years from losing your vision, but you don't notice every day that anything Better. And by the way, the eye drops could be a little irritating.

Maybe it's things a little for a minute or two when you put IT in your eyes, some people are even less tolerant of the eyedrops. 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 with prescribed medications where they don't feel or notice a difference in a daily way.

I realized that we can't stop aging yet um but right now you can't stop aging and age is a respectful for gAlicia minor standing is so is smoking or raping nickey and so is alcohol and by that reasoning, should people strive to drink class and slow class, including viking, less less if they are concerned about a and not just .

got home a maculated generation, actually macular generation as a couple major risk factors, macular generation, aging, just like with cloud, a major risk factor, smoking, including exposure to second hand smoke, major risk factor for mac degeneration and for the progression and vision loss potentially associated with macos generation.

In the case of microgeneration, there's also a couple of genes that we've sequence the human genome and there is a couple of genes associated with maco generation too that's less true for your typical run of the mill adult glow coma. There are genes for the pediatric and infantile forms of glom. So yeah, smoking one hundred percent, including in a 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 I doctor to have these conversations with patients because you kind of feel like, well. You know, they must know that already. And i'm trying to be a good guy in the room with the patient, convince them to use their other medications.

But it's it's important for us IT also, as I care providers, to reinforce the message with our patients, say smoking, terrible idea, uh, for market at the generation also for globular. You know globular is interesting because the optic nerve where IT to generate, it's kind of write at the head of the optic nerve where IT exits the I it's what we call a water shed zone. It's kind of the edge of two blood vessel supplies.

If either of those blood vessel supplies are a little bit short on blood or oxygen supply to that optic nerve head, your glow coma is gonna a get words, your optic nerves going to be under fed. And that's gonna worse in this degenerate process just by not having, all right, nutrients and oxygen. So the other thing is that, especially for gama, everything that we talk about for being hurt healthy for the rest of our body is is almost certainly true for glow kuma.

And so I also always council glow coma patients. It's not just no smoking but eat healthy, have a multivu and uh get some exercise. All those things that are good for your cardio accused system are going to a be good realize in general and in particular if you have gloomy uh, or risk high risk for I realized .

that smoking or raping are problematic for glock, oma and for maculated generation but we can have a conversation about gloomy without at least mentioning canna. I didn't entire episode about cannabis, which touched on some of the real dangers of very high T H C concentration cannabis. This lost me, if you followers, i'm sure no problem.

Because what was important was to convey the fact that the cannabis out there now is comes in a variety of different strings and ratios of T H C to C B D. There some severe risks of high T H C, especially in the Young males um 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 would say it's not as about as alcohol. But guess what, we didn't entire episode about alcohol.

And there the message is very clear. Zero is Better than any and two a week is probably the limit in for an alcohol lic. Zero is the rule. So with canvas is clear by my read of the data that IT can lower high pressure, which may undermine the progressions of alcoa somewhat.

But if people are smoking that cannabis, is that therefore going to offset any game that one would get from that cannabis? And then how does one account for the potentially problematic aspects of very high T H. C. cannabis?

It's a great question。 And the truth is, is that in most patients, cannabis will lower the high pressure. The problem is, is that really only lows that high pressured during the period that you're high from the canabal? 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 inflation. Tion IT dries out your eyes.

So it's also very bad for that perspective now. So the problem with cannabis is not that IT doesn't work to lower the 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 describe. Could you go out and be high from cannabis twenty four hours a day, seven days a week, for the next twenty years?

I'm sure some people have tried and succeeded. But right, that's not practical for most people. And certainly for Young people. That could be really especially problematic. I should.

So so I recommend not taking that approach. But that said, I am definitely not to care 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, turns out you've talked a lot over the last couple years about diane curbs and circadian rythm IT. Turns out that our high pressure also undergoes the circuit I N hythloday.

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've a lot of patients who they come into the clinic physic, the high pressure looks Normal, but it's actually quite a bit higher when they're at home. And that critics explaining some fraction of what we call Normal pressure globe a IT just looks Normal during the day.

It's actually high at night. And so in particular, some patients, I certains have some patients who are using these products like, let's say, before bad and if it's controlling the high pressure at night, rather asleep, when the high pressure would have been the highest IT may confer some protective advantage over time. But that's that again, like for most patients, is not to be the primary approach. I'm most excited about the idea of um um you know laboratories or companies figuring out which the compounds within these uh cabin oids they're called within these products are actually responsible for lowering the high pressure. And could we get like a more potent I specific long acting drug that basically derived from the concept of cannabis, but works Better than is more compatible with not bringing along all the other adverse elements that can come with canvas use?

You mention the circuit dian rythm eye pressure, and the after high 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 abstraction or a paper a few years ago, a meeting that you and I both attended, what they said, that if people slept with their head below their feet, high pressures were higher than if their head was slightly elevated above their feet. And for somebody who has got coma, 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 gangland cells.

absolutely. And we will sometimes council patients with severe locum a, especially if they are 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 thirty degree sleep angle going.

What I don't want to do is interfere with a person sleep, because I just, I fundamentally feel for the total health of the whole human being, getting a good nigh sleep is maybe more important than that thirty degrees is. And if trying to sleep up until is thirty degrees is gonna lead to kind of restless, difficult sleep night, i'd rather the patient get a good night sleep. But if they can tolerate IT, and especially if they have a sort of A A tough version of gala, then we ll let them try, see if they can sleep up.

The other really interesting question that arises is, uh, does which side you sleep on? A fact, uh, at which I might have worse, go, come, go. Comment is almost always with, with a few rare exceptions, almost eyes, a disease of two eyes.

But I can present very asiedu ally. In fact, it's quite common of one. I kind have worse damage than the other. And and we don't know fundamentally why that is. But one hypothesis was gotch.

Maybe if you're sleep on the right eye and then you're right eye have worse low cuma because the pressures 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. Uh, a couple studies have said the lower eye have over.

A couple studies have said the higher I will have worm, so the opp shot is that probably doesn't matter outside 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 the night. You're spending a similar amount time on each I that .

you brought up that point. In terms of macular degeneration, i'm curious about the things that people can do is supposed to the dots in order to craps offset maca generation. One of the things that i'm intreated yer, the results of glen Geoffrey laboratory over 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 now, too, publish 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 a minutes, a few times a week, could offset some of the vision law associated with age related acute degeneration in people older than forty. That's my understanding of these studies. And there's a theory there about enhancing function of my country and photo receptors by reducing reactive oxygen species.

There's a home mechanistic hypothesis. But my question is, is that the sort of protocol that produce a significant enough offset of mass lodge generation like we should all be looking at red lights in the morning? Um or is IT still too early days in order to really conclude that?

I think the data is very compelling. The data are very compelling that this kind of read or near infrared light therapy can be, at some level, no protective. And yes, the data suggest that, uh, kind of rampling up, I functioning my economy is a part of that, a 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 maaco degeneration kind of degenerates, but also for object opposites, you know, like low common retina ganglions cells, the cells that Carry all that visual information from the eye of the brain, they're chockfull amidon re, too. And and so the idea that this could be a therapeutic approach, I think, is 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 are an optimal wavelengths? How many minutes doesn't matter when during the day you provide that light or how many minutes or hours um these are still very much open questions. You know what's the dose, what's the delivery? Um but it's it's it's it's very promising looking in biological premise, and i'm excited to see where that good because again, that's like a that's a very accessible uh sort of therapy euros approach that could be brought to a very broad swath of of people. So i'm like about art and means .

drop and completely non invasive. Um I should probably mention a warning, which is if people are going to decide that. They are 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. So that I think this is why you're pointing the fact that we need established protocols and 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 .

to have that yeah that's absolutely actually uh, light effect. Um we talked about this a little bit earlier um 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 nearsighted ess in children in school age children and so I think we're really just on the costs of really understanding the biology of how these different light therapies might be leveraged maximum to to maxim our eye health uh and both during development and at the other end of the spectrum as we age. Um so it's an exciting area and I think this kind of photo therapy is uh you know um a very hot top for research right now, very hot top.

One has to wonder whether 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 humanity before a child, or perhaps an adult, also suspends a certain number hours outdoors. I mean, if we're just filling in the blanks that are neglected nowaday because we're spending so much time indoors under artificial lights.

in front of screens, yeah yeah, that's a yeah very thoughtful possibility.

Have a couple of we don't have to call them quick questions, but common questions that perhaps have a brief explanations. For instance, I put out a request for questions in an anticipation of this episode, and I got a lot of people asking water flowers in the eye. And is there anything that people can do to get rid of flowers? yeah.

R I, when we're born, is actually filled in the middle of IT with a jelly. It's not just flew at its kind of a jelly. There's college and fibers, and thankfully, the whole jelly is largely invisible.

So the light can get through our ee back the retina without being impeded as we age. Those different fibers and jails shrink and contract and they peel off of the back of the redness. So there's just in the middle. Your eyeball doesn't shrink because IT fills in with with fluid, with salt water, basically.

But the jail part rinks and as IT rinks and also puls peels off the retina, a IT can pull off kind of little tiny retina bits, not important to your vision bits, but just like little tissue bits, and also as IT congeals, that kind of a can get little conclusion in the jelly. And we perceive those as floors you little, almost semi trans, loose, in some cases, kind of british black tish. Sometimes, sometimes you get a big one.

If IT peels off the edge of the optic nerve in the back in the eye, as happens, we call that a posterior vittoria attachment you can actually see like a moon or a half moon floor uh in your vision these are very frustrating to a lot of people um and uh 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. Chew up all that jelly replaced, always salt water.

Try to get rid of your floats. There's risk associated with that surging. We use IT very effectively in a retina detachment or other diseases, bad diabetic retina b but the leading inside the eye we can take out the jellyby from the ee replace IT with with with salt water.

Uh but that's not um you know putting patients through the risk of that surgery just to get rid of a couple of floors or a few floors that probably you are going to go away over the next few months. I actually like to tell patients it's 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 worry 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 two will go away. These two will appear. A eventually you'll stop having floors. Most patients, you'll stop having floors. Um so we really don't like to put a patient risk by intervening.