Healthy eyes – new therapies maintain sight | DW Documentary

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Eye conditions are on the rise. From cataracts to near-
sightedness and macular degeneration — millions of
people worldwide suffer from poor vision.
Reading fine print is almost impossible. You have to hold
the book up to your face.
Young people are increasingly affected -- around 217 million
people are visually impaired, and 36 million
are blind worldwide.
Our sense of sight plays a vital role in our lives, and
things are very difficult for people who are blind.
Modern surgical techniques are less invasive
and can help restore eyesight.
It's a quantum leap — a minor revolution.
From stem cell therapy to laser surgery — new
treatments are giving patients hope.
This residential development in the city of Mainz, Germany,
is home to Lilli, her brother Max, and their parents. 13-
year-old Lilli is an ordinary teenager - she goes to dance
class twice a week, and she likes to chat with her friends.
Lilli has been near-sighted since the fourth grade. She
has minus 4 diopters in her right eye,
minus 0-point-5 in her left one.
When Lilli takes off her glasses, the world looks like this —
even nearby objects appear blurred. And her
eyesight is continuing to deteriorate.
I see things best when they are very close, but it keeps
getting worse. When I take off my glasses, even my hand
looks blurry. Anything further away is even blurrier.
Nearsightedness - or myopia - is the result of the shape of
the eye. Normally rays of light entering the eye are refracted
so that they focus on the retina at the back of the eye.
When the eyeball is too long or the cornea too curved,
the light focuses at a point in front of the retina.
Objects that are further away appear blurred.
Our eyes are designed for distance vision. Spending a
lot of time looking at nearby objects puts strain on our
eyes. Our eyes then gradually deform so that we can see
nearby objects more easily. But then we end up not being
able to see objects at a distance as well. That's
what's called being nearsighted.
Myopia is partly hereditary. Lilli's parents
are also nearsighted.
Lilli has an appointment at the Eye Clinic in Mainz for a
thorough examination.
Norbert Pfeiffer heads the eye clinic, and is a specialist in
near-sightedness.
First comes the exam with the slit lamp.
So put your chin on the chin rest.
He first examines the ocular fundus and optic nerve in both
eyes. Near-sighted people should get a vision exam at
least once a year. Myopia can promote the development of
other serious eye disorders. It increases the risk of retinal
detachment and cataracts.
Lilli is nearsighted, at minus 4 to 5 diopters. That's fairly
nearsighted - not as much as some, but it's quite a lot. She
started out with a quarter of a diopter, when she was
about ten. That tends to increase with age,
until maybe age 18 or 20.
For Norbert Pfeiffer, Lilli is an example of how
nearsightedness is on the rise. He's investigating the cause of
this increase in a large-scale German study involving
15,000 patients. The study has been underway for 12 years.
The longer you go to school, the more near-sighted you
become. For every year you go to school, you get a bit
more near-sighted. And that goes for university degrees —
the longer you study, the more nearsighted you
become. So nearsightedness has a behavioral component.
So myopia isn't just hereditary -- our lifestyle plays a role.
Near-sightedness is linked to educational levels
and is on the rise worldwide.
In Asia, even more young people are nearsighted. In
some countries, up to 80 or 90 percent. We think one
factor might be the age at which children start school. In
some Asian countries, they start school when
they're just three or four years old.
In Taiwan, for example, myopia has reached epidemic
proportions. Up to 90 percent of schoolchildren in major
cities are nearsighted. Schools and universities are pressure
cauldrons. The workload is heavy - even more than in
Europe. Long hours of studying lead to more near-
sightedness. What many don't realize is that if myopia
remains untreated, it can even lead to blindness.
Russ Khan shrugged off his vision problems for years. A
software engineer, he was working on a new program
when he suffered a retinal detachment. He underwent
12 surgeries, but nothing helped. Russ Khan is now
blind. At one point, he contemplated suicide.
I can hear. I can move. They're always going to be
there for me. That's the love. And because of the family
bondings. They made me realize that perhaps if I'm
settled down more myself, I can do something. I can still
do something for myself and others.
Russ Khan now goes to schools to tell his story and
raise awareness about near-sightedness.
In the classroom, he tries to connect with
the children on a personal level.
Every half hour, we let our eyes have a break. How long?
Ten minutes, they reply.
And lastly, how long should you play outside every day?
Two hours!
The children are supposed to give their eyes a break from
schoolwork. But long hours hitting the books is ingrained
in Asian culture. It's an uphill battle. The WHO estimates
that half the world's population will be shortsighted
within 30 years. But simple measures
could make a difference.
The most important thing is to send children outside into
the sunlight for two hours every day. We know this is
the best way to prevent nearsightedness.
An instrument called a luxmeter is
used to measure light intensity.
You'd probably say there's plenty of light in this office,
enough to work by. But the meter is showing 102.5 lux.
That's not much light. The light is much brighter outside.
Even bright lamps are no substitute for daylight. Eyes
need sunlight — the chance to view objects at a distance.
Outside, the light intensity is 100 times higher:
I took the meter outside. Even though it's cloudy, we're
seeing 13,600 lux. That's much higher. If it were sunny
out, it would be even higher than that.
Bright sunlight can be up to 100,000 lux or more. It may
seem trivial, but daylight works wonders
against nearsightedness.
Back at the clinic, Lilli is undergoing another a vision
test. She's supposed to read the numbers off the chart.
She's asked if she can read the largest number.
Even the largest number is blurred.
Norbert Pfeiffer will continue monitoring Lilli's vision and
making sure she gets enough sunlight. It's the only way to
treat her nearsightedness and preserve her vision.
An eye clinic in Cologne, Germany, specializes
in other vision problems.
Alfred Remmert is 60 years old. He lives an hour away and
comes here for treatment. Remmert runs a company
with over two thousand employees and often travels
abroad. His vision has been deteriorating
for some time now.
This is what it looks like out the window. This is what
Alfred Remmert sees. And it's getting worse.
It's all kind of foggy. Blurry and foggy. Right now I'm still
coping but ordinary activities are getting more difficult.
Alfred Remmert has come here for a consultation with
Claus Cursiefen. He's chief physician at the clinic and a
leading expert in corneal disorders. His exam shows
that Alfred Remmert is a good candidate for surgery.
The lens and cornea are clouded. So two layers of the
eye are clouded. In one surgical procedure, we'll try
to eliminate both sources of this clouded vision. We'll
replace the lens, and transplant the
inner layer of the cornea.
The transparent cornea is part of the outer casing of the eye,
and serves as a kind of windshield. Behind it, the iris
opens and closes to control the amount of light entering
the eye. The lens focuses the incoming light to create a
sharp image on the retina. The optic nerve then transmits
that information to the brain.
Two hours later, the surgery is underway. Claus Cursiefen is
preparing the corneal transplant. The clinic has its
own eye bank - with corneas from organ donations. The
cornea does not have a direct blood supply. For that reason,
it can be removed up to 72 hours after death.
Claus Cursiefen carefully removes the edges of the cornea.
The blue contrast agent helps him guide
the delicate incisions.
The cornea is only a few thousandths of a millimeter
thick. Using a precision instrument, he removes the
inner layer of the cornea.
The delicate tissue is rolled up, and then placed on injector.
The instrument will later help him position the
cornea in the patient's eye.
The patient is wheeled into the operating room. Alfred
Remmert already under general anesthesia.
The eyelids are held open with retractors.
With three tiny incisions, the diseased inner layer
of the cornea is removed.
This is the inner, clouded layer of the cornea, which is
selectively removed. It is about ten-thousandth of a
millimeter thick. We only remove the diseased layer
here and can leave the rest of the cornea in place.
That speeds up the healing process. Just a few years ago,
the entire cornea would have been transplanted.
Then the injector is inserted into the eye and the thin
corneal layer is unraveled.
The blue-colored structure in front of the eye is the
transplant. Now we have to put it in the proper position.
Now we fill the eye with a gas. The gas bubble presses the
transplant firmly onto the back of the cornea. We don't
sew it on — it's held in place by this gas bubble.
The gas bubble pushes the transplant onto the cornea. In
order for it to attach properly, the patient will need to lie on
his back quietly for several days.
Everything goes smoothly and the surgery is a success.
Sigrid Roters helps manage the eye bank at the clinic.
Today she retrieved a donor eye from the pathology
department. The clinic in Cologne opened its
eye bank in 2000.
Sigrid Roters carefully examines the eye for any sign
of disease. Then she detaches the cornea bit by bit. Human
corneas are still used in transplants, but artificial
corneas are now under development.
The doctor places the cornea in a nutrient medium and
maintains the incubator at the perfect temperature, ready
for the next transplant surgery. Demand is high.
6,000 corneal transplants take place each year in
Germany and there are another 6,000 recipients on
the waiting list. Of course, we would like to have more
donors to meet this demand.
Five weeks after the procedure, Alfred Remmert is
back at the Cologne clinic for a checkup. Since corneas don't
have their own blood vessels, they're rarely rejected by the
recipient's immune system —
unlike with donor hearts, for example.
But he did have some difficulties at first.
I'm doing well now but the first 14 days were hard. My
eye was very sensitive, I could hardly open it. My eye
was watering and my vision was blurred. Then my other
eye started watering, too, and felt the strain. But about
ten days ago, things got a lot better.
The surgery was a complete success, and the healing
process is going well. Before the surgery, Mr. Remmert's
vision was down to about 40 percent. Now it's at 90
percent and it will continue to improve.
Alfred Remmert's vision in his right eye is
almost normal again.
The University Hospital in Bonn, Germany, focuses on
one of the most common eye conditions in the Western
world: age-related macular degeneration, or AMD.
Karin Krause-Zillich suffers from what is called wet AMD.
This is how healthy eyes see the world. This is what Karin
sees. She is almost blind in her left eye.
Wet AMD is less common than the dry form, and it
progresses more quickly. At first Karin Krause-Zillich barely
noticed the symptoms.
When I was doing my make-up and would close one eye
to do the other one, I thought, something's not right. There's
a dark spot that shouldn't be there. Then I saw my
ophthalmologist. He did several tests
and I got a diagnosis.
The macula is a small area in the retina at the back of the
eye. It's where our vision is the sharpest and it contains
most of the light sensing cells. In AMD, blood vessels leak
fluid or blood into the macula. That leads to swelling, and
damages the photoreceptors.
Frank Holz specializes in the treatment of macular
degeneration. Although AMD cannot be cured, its
progression can be slowed.
The dangerous thing about this condition is that it
irreversibly destroys the photoreceptors located in the
center of the retina, in the macula, where our vision is
the sharpest. That's what allows us to read, recognize
faces, and drive — so many everyday activities rely on it.
Once the macula is destroyed, people find themselves
with a serious disability.
Karin Krause-Zillich comes in for a check-up every four
weeks. Left untreated, the disease progresses very quickly.
These green lines indicate where a cross-section of the
retina is being displayed. This allows us to examine the
structure of the retinal layers, and see where
there might be fluid.
Today the news isn't good. The scans show a small gray
sickle on the retina. Karin Krause-Zillich will need
another injection of the drug that's used to
treat the condition.
The preparations are complex. Eyes are delicate organs.
Everything needs to be sterile to ensure that bacteria won't
enter the retina.
The drug is injected directly into the eye. The drugs inhibit
a growth factor that promotes the formation of
new blood vessels.
The procedure itself takes just a few seconds.
It's like a little prick on your finger. It's over in a moment
and that's it. I'm grateful this treatment exists.
She's responding to the treatment quite well. But
we'll have to keep repeating it. This is a chronic condition
that won't go away or get better.
Not all patients manage as well as Karin Krause-Zillich.
Many patients discontinue treatment, and the drugs
don't work for everyone.
At the Sulzbach eye clinic near Saarbrucken, doctors are
investigating new therapies. Boris Stanzel is a
leader in the field.
He specializes in retinal surgery and stem-cell research
and is currently running a major clinical study on AMD.
Ingrid Moser is one of 150 patients who are taking part in
the pilot phase of a new stem-cell therapy. She was also
receiving the injections, but they stopped working. Using
this scanner, Boris Stanzel checks to see how quickly the
disease is progressing.
The macula is in the middle, and here's the optic nerve.
This black area around what was the macula is where the
cells have died, and it's getting bigger.
The disease is very advanced. Ingrid Moser's vision is only 5
percent of normal in her right eye and 10 percent
in the left one.
The new therapy aims to reprogram stems cells
extracted from the participants' blood. Then the
dead retinal cells will be replaced with the
reprogrammed ones.
We're hoping to replace cells in this layer here. Right here
it's still healthy. And you can see right here, they're missing.
If we can get new cells to take root in this area, then we
might be able to revive the outer portion of the retina,
which is still in relatively good shape.
Another benefit of this kind of stem-cell therapy is that it
doesn't involve any potential ethical concerns.
We don't have to use embryonic stem cells. We
extract the stem cells from the patient's own blood, in
much the same way that you do in a bone marrow
donation. Then we convert them into the proper cells in
the laboratory, and implant them back into
the patient again.
The IBMT Fraunhofer Institute is located just a short distance
from the clinic, and is collaborating in the
development of the new therapy.
Boris Stanzel is meeting with Hagen von Briesen, director of
the stem cell laboratory. The two scientists will check on
how the reprogramming of the eye cells is coming along.
The researchers here work with cell cultures. First they
reprogram the blood cells, turning back the clock to
return them to an undifferentiated state. Next
they multiply the cells, and then reprogram them. Those
will become new tissue cells - including retinal cells.
The new retinal cells can be seen under a microscope.
Reprogramming them is complex.
We have to treat these cells with specific biological factors.
That allows you to return the cells to their original state.
It's quite an amazing accomplishment, something
we never dreamed we could do. 20 years ago, it would
have been unthinkable.
The researchers then preserve the new retinal cells. To store
them long term, they'll be frozen in a container filled
with liquid nitrogen at a
temperature of minus 140 degrees Celsius.
Each sample is scanned and labeled for each patient. The
container is then placed in the stem cell bank.
With 20,000 samples so far, and 15 different partners in
industry and medicine, this stem cell bank is unique in
Europe. It's a promising project, and researchers hope
that it might one day provide new therapies for eye
conditions that today are untreatable.
This therapy won't be available any time soon. But
we've been able to show that the therapy would work in
principle. Now we'll have to get through the approval
process, which is time consuming and involves a lot
of regulatory steps. It's a process that takes several
years here in Germany.
The researchers have laid the groundwork for a
revolutionary new therapy - using reprogrammed stem
cells to restore vision. In a few years, this might be a major
advance in preventing AMD-related blindness.
At the Medical University of Vienna, scientists are also
staking out new territory. Ursula Schmidt-Erfurth is
director of the department of ophthalmology and optometry,
which is investigating new diagnostic procedures
for eye conditions.
Our eyes are our window to the world. But we can also
look into the eyes, into what's happening inside
them. We can look into the clear cornea and the clear
lens, which we also call the clear media.
Ophthalmologists can look inside the eye and laser
scanners can also make the surface of the retina visible.
Laser scanners can also peer into the retina's deeper layers,
and create a highly detailed image. With 40,000 separate
scans, the device can examine the retina in 3D.
Once the laser scanner creates an image of the patient's eye,
the high-resolution images are analyzed with the help of
artificial intelligence.
The system, or the computer, basically works just like the
human brain. It learns and gathers experience, and gets
smarter. You can feed the computer an infinite quantity
of data from an infinite number of patients and an
infinite number of medical conditions. And the system
learns to how draw the correct conclusions.
Ingeborg Nowak suffers from age-related macular
degeneration. The 3D scan of her left eye was compared to
the images of thousands of
other patients in the database to detect cell changes.
The new diagnostic procedure identified tiny defects
developing on her retina in time for them to be treated.
If that exam and the follow-up treatment had been
delayed, I probably would have lost the vision
in my left eye.
In the data laboratory, IT experts are fine-tuning the
algorithms that will be used to generate an accurate
diagnosis and devise personalized
treatment regimens.
The algorithm can analyze millions of pixels very quickly.
Then it tells us whether the disease is progressing,
whether the current treatment is working, or
whether a new therapy might be more effective.
The algorithms are so effective that the system will
soon be used to diagnose other health conditions.
We think that in the near future, this system will allow
us to reliably identify signs of cardiovascular disease at an
early stage, and help prevent heart attacks in
high-risk patients.
Our retina is like a window to our blood vessels -- tiny
changes in our vascular system can be identified in
our eyes far earlier than elsewhere in the body. One
day, eye scanners might be used as a kind of early
warning system.
Karin Schultz-Igast is about to undergo surgery. She suffers
from cataracts - the lenses of her eyes have grown opaque.
Cataracts gradually grow
worse and can lead to blindness.
This is normal vision, and this is how Karin Schultz sees the
world. The condition has a major impact on her daily life.
For example, she can no longer drive.
Stars at night look like little flowers, for example. They
have a halo of little dots surrounding them.
Cataracts grow more common as we age. 90 percent of
people over the age of 65 will develop cataracts. Other
symptoms include difficulty with bright light, and difficulty
seeing at night.
Karin Schultz's vision has deteriorated to the point
where she's decided to have surgery at the
Augsburg eye clinic.
A preliminary exam will show how far the cataracts have
progressed, and whether she's suffering from any
other eye disorders.
Three different tests are carried out.
The optician records the results.
This is the front surface of the cornea, the back surface, and
its thickness ?. Here's the cornea, the anterior chamber
depth, and the clouded lens, and here we have key data
about the cornea.
Felix Rombold explains the procedure. Doctors still don't
know exactly what causes cataracts. They believe it's
part of the natural aging process, which also
affects our eyes.
For Felix Rombold, this is a routine procedure. He carries
out 20 to 30 cataract surgeries a day.
The clouded lens is replaced with an artificial one that
remains in place for the rest of the patient's life. This
special artificial lens also reduces corneal curvature. It
provides sharp distance vision, with a lower range of
about 60 to 80 centimeters away.
Felix Rombold puts the femtosecond laser into
position. This technology enables tissue to be cut with
high speed and precision. The device costs 500,000 euros.
The doctor positions the eye and cuts a circular opening
into the anterior capsule with the laser.
The laser created a perfect opening in the anterior lens
capsule. I'm flushing the lens with saline solution now so I
can move it.
The lens remains in its capsule. With the help of the liquid,
the doctor can move the lens and gently remove it.
Now I'll to use the ultrasound device. The eye
remains stable.
The laser dissolves the nucleus of the lens, which
is then extracted.
Now we've completely removed the lens. What
remains is the patient's own lens capsule. The artificial
lens is inserted into it.
It's high-precision work. Cataract surgery has been
transformed over the past 10 years.
The incisions are getting thinner and thinner. Today
they're just two, or two and a half millimeters thick. That
means we're intervening in the eye, touching and moving
the eye, far less. And that in turn speeds up healing and
considerably reduces the risk. The rehabilitation
phase is much shorter.
Around 700,000 of these outpatient procedures are
carried out in Germany every year. Complications such as
bleeding inside the eye or infections are rare.
About 10,000 kilometers to the south, a convoy is making
its way through Rwanda in eastern Africa.
The ophthalmologist Silvain El-Khoury is on board. He and his
team are traveling from the Kabgayi Eye Clinic to an
outlying area. The doctors make this journey
only once a year.
This is a mobile clinic. We take all our equipment with
us — our surgical microscope, our instruments — and go to
remote regions to carry out surgeries. We mostly treat
cataracts, which sometimes even lead to blindness.
The team has reached its destination, an outpost an
hour's drive from the clinic.
The patients are already waiting. Silvain El-Khoury's
work is funded by the German CBM aid organization.
The outpost is a lifeline for people who can't make the
journey to the city.
Philamene Nyirami has been blind for five years now. She
had to move in with her daughter because she could
no longer manage on her own.
The exam shows that she has cataracts, and the disease as
progressed to an advanced stage.
She can only see shadows against the light. Light and
shadows, basically, maybe the outlines of shapes.
But definitely not faces.
Philamene Nyirami was unable to make the trip to the
city to see a doctor.
It will depend on the doctors here and God! I have
confidence in doctors who are always fighting for our
good health. I can't treat myself, after all. I have to
have hope in them.
Silvain El-Khoury decides to carry out the surgery on the
left eye that same day. The next day, he'll operate
on the right eye.
One of the rooms is converted into an operating room.
Everything is adapted to the conditions in Africa. The
doctors use simple equipment that requires little
maintenance.
They also employ a special surgical technique.
The main difference is that I remove the clouded lens
using what's called the fishhook technique. I use a
sort of fishhook that I make myself, out of a syringe. Now
I'll make a tunnel incision through the sclera — about
two millimeters from the limbus. It's a self-sealing
incision, so no stiches are needed.
15 minutes later, he's reached the lens.
Here's the thick, clouded lens. You can see that it's turned a
brownish red. Far too clouded for anyone
to see through it.
Silvain El-Khoury now inserts the artificial lens. It comes
from India and costs only a few euros, but it works.
I use tweezers to slide it into the same spot where the
original lens was. I'll turn it a bit to make sure it's in the
right position. And then I'll flush the area out again.
An antibiotic ointment prevents infection. 25 minutes
later, the surgery is done.
The procedure went very well, with no complications.
The next day, Silvain El-Khoury examines the patient. The
doctor carefully removes the bandage.
Ask her: Does she see my hand moving?” “Yes.”
How many fingers am I showing?” “Two.”
“Now?” “Five.”
The results look good. Next comes a vision test.
The surgery was a success. Philamene Nyirami can see
even the smallest symbols at the bottom of the chart.
I'm very happy to be able to see the people around me,
everything around me, I'm very happy.
This very gratifying, of course. It reaffirms me in my work
and in the life I've chosen for myself.
For the first time in years, Philamene Nyirami is able to
make her own way across the room. She's still a bit hesitant,
but thrilled that she can see again. The procedure cost
about 30 euros.
The world we're working in is much more difficult. We have
fewer machines and diagnostic options. The
instruments we use are often older ones. So we face a lot of
challenges, especially when it comes to surgery. But we
have a good team. They really do the legwork for us and
make our own work much easier.
Two days later, Philamene Nyirami's other eye also has a
new lens. She can see again. Assistants from the CBM aid
organization drive her and her daughter as far as they can —
to the end of the paved road.
They'll have to make the final stretch home on foot. The day
after surgery, the 20- minute walk is a challenge — but she
has a new life to look forward to.
I'm really very proud to see people smiling after a long
time without vision. Then after just like ten minutes, five
minutes or ? their vision is restored and a lot of persons
who is useless becomes again useful for their community,
for the society and for the country in general.
Her children, grandchildren, and the entire community
have gathered to welcome her return. The last years have
been hard— unable to see, she was isolated from day to day
life. The entire village shares in her joy.
This is a miracle, that I can see! I am very happy! I'm
now celebrating with my children.
Philamene Nyirami spent five years waiting for surgery. Now
her vision has been restored.
In Rwanda and around the world, a lot of progress in
treating eye conditions has been made. But new
challenges are also emerging. The use of smart phones, for
example, is a problem. And as life expectancy rises, eye
disorders are also on the rise. But there is hope.
Eye surgery will improve. More drug therapies will
become available. I think we'll make a lot of progress in
preventing the deterioration of vision and
the loss of vision in old age.
New surgical methods, better artificial corneas, retinal
implant microchips — the future of medical treatment to
preserve vision is a promising one.
I'm really pleased. I'll have surgery on my other eye, too.
Reprogramming stem cells is a great leap forward — but
researchers are convinced that even more
progress will be made.
In the next few years, we'll see a great deal of potential
in the field of gene therapy. We'll also see advances in
pharmacological and microsurgical therapies.