As the old adage says: seeing is believing. But what if that sight was compromised, disrupting your entire worldview? Three area specialists discuss new advancements in the field of ophthalmology and how to treat—and prevent—degenerative eye diseases, helping patients navigate an often blurry path forward.

SRQ: There are several different parts of the eye—the cornea, retina, etc. Do doctors specialize in one segment? What does it mean to have a degenerative disease in each one of these parts of the eye? Dr. P. Dee Stephenson (Stephenson Eye Associates): I’m an anterior segment surgeon, so I deal with cataracts, a degenerative disease that happens to the aging. Dr. Soscia is an anterior segment specialist and Dr. Mali is a retina specialist. When you’re looking at a patient, they come in with visual complaints and lifestyle complaints and you have to evaluate the general health of their eyes starting from the surface—whether the cornea is healthy and whether they have dry eye or corneal disease or both. Whether they have a cataract that is affecting their vision. Then you look at the rest of the health of their eye—if their retina is healthy or not. If not, I’d send them to Dr. Mali. Then they are evaluated for what their outcomes may or may not be. It’s a whole conversation with the patient regarding cataract surgery: about their lifestyle, about whether or not they want an intraocular lens implant—what is best suited for them and their lifestyle. Do they want just the government-issued intraocular lens or if they want the upgrades with the Femto and the astigmatism correction and the premium packages of the multi-focals or the Crystalens. Dr. Joshua Mali (The Eye Associates): You can really base your focus on which part of the eye you are talking about. The big three that come to mind for me are: cataract, glaucoma and ARMD, or age-related macular degeneration. When you use the term degenerative eye disease you’re presuming age-related. With advancing age, these three big disorders advance over time. Our focus in our field is to address those three big issues and have treatments available to patients to help either slow the progression or even cure the disorder itself. Dr. William Soscia (Center for Sight): A lot of the time the way I describe this to patients in a simplistic fashion is that I think of the eye as having two jobs—analogous to a camera: the back of the eye is kind of like the film and the job of focusing is in the clear window of the eye called the cornea. There are a lot of diseases, some that are age-related in the cornea, but some we see in young people—genetic degenerative diseases like keratoconus, where the cornea, that window, should be shaped like a nice, round basketball to make focusing even and instead it’s shaped like an oblong football and doesn’t do a good job focusing and in severe cases the person will need a cornea transplant. Dr. Stephenson talked a lot about cataracts and implants, which are what I specialize in as well. And then what Dr. Mali specializes in is the retina, which is like the film of the camera. The breakdown of the central part of the retina, called the macula, is called macular degeneration. The other big one is glaucoma, which is a disease of the nerve. I describe this to patients like a cable that runs from the eyeball to the brain. When you have a degeneration of that nerve, it results in the loss of peripheral vision and even central vision. That’s what the specialties tend to tailor to—things are so sub-specialized in the surgical techniques and the medicine. I have a good idea because in our practice we have a couple doctors like Dr. Mali, but even there I have a very limited knowledge of retina issues, and vice versa. We tend to get really good at our own specialty. Stephenson: Patients are smart these days. They come in with a lot of information that, for me, 20 years ago they didn’t have. Treatments are different, especially with the anterior segment specialty—the technology there is the fastest growing technology in any subspecialty there is. But also for the retina, there are so many things they can do now that they could not do before to cure and/or maintain patients’ vision. It’s an exciting time in ophthalmology. All kinds of FDA stuff just got approved, a new dry eye treatment—the first prescription in over 10 years. Two new implants got approved, the presbyopia implant, the Rain Drop got approved—four things in less than a month’s time. Technology is our beacon; it modulates which direction we go in.

A lot of people think that eye surgery just means LASIK. What are some of these new technologies that are offering solutions besides LASIK? Stephenson: Technology comes with a price tag and the government, unfortunately, doesn’t care if we take your cataract out with a fork. It is all about the outcome. You can have the want and the need but if you don’t have the financial wherewithal, some of the options are not as available. But a lot of practices give financial help. I always tell a patient whatever their decision is for themselves is the right decision. If you can, instead of getting a bicycle, get the Maserati. And there are other options in between that are very good options too. Femto is pretty much, at least in our three practices, how all our cataract surgery is done. Soscia: Often times [patients are] getting the impression, “I can go with OK surgery, better surgery and best surgery.” So I always start off by saying, “We’re taking great care of your eyes, we have fantastic experience and this mostly has to do with reducing your dependence on glasses.” That’s how I try to present it to them, so they don’t feel like they’re getting a second-rate surgery. We’re taking great care of them, using great technology. It’s just there are some differences. Mali: And I can speak to macular degeneration—there’s fantastic new treatment now available with injectable medications. It’s a big-time problem; there are almost 3 million Americans right now that have vision loss from age-related macular degeneration. That number is actually going to jump to nearly 6 million people in the year 2050. We currently have three injectable medications that I use in my practice to help treat patients with macular degeneration. Before this, a decade ago, all they had was a cold laser, which wasn’t really that effective, and now we’re able to preserve vision for longer and keep people seeing a lot better. With macular degeneration the future is also bright for new treatments. Soscia: When I came to town in 2002, for the first couple of years all those treatments didn’t exist. I don’t do retina but our retina specialists only had the laser. That was basically what we had, and now we can send them to Dr. Mali, who could take them from being almost blind to, in a lot of cases, reversing a great deal of it and even restoring vision. As much as we are fired up about our particular specialties, I’m just as fired up for my patients that I can send them to people like Dr. Mali. Stephenson:  Vision loss is a life-long thing, so we need to be in good stead with our colleagues because I don’t do what Dr. Mali does—I need his help to preserve the quality of life and the quality of vision for someone. I don’t know much about the retina but I know who to send people with retina issues to. But it’s the technology that’s  off the grid. It’s a really fast-growing field. Soscia: We really set the bar for that—just as fast as we’re seeing the technology increase in other facets of medicine, I think we’re a couple of exponents even higher. In just a few months, we’re seeing all these things. Every time we think we’re at the best, we have another new implant.

How do you explain to someone what an implant is? Stephenson: Think about the cataract being a chocolate-covered M&M. The lens is the chocolate. Inside the sack, or the candy coating shell, is the anterior part. You make a hole with a laser or manually, and you disassemble the cataract (or the chocolate) and make a pattern with a Femto laser and then you suck it out and now you have a space. In the past, if you took that cataract out and there was no implant, you’d have to wear those big, thick, Coke-bottle glasses. Now, the lenses are customized with measurements before surgery and then implanted with an aberrometer. In the operating room, we can titrate the power of the implant that goes in there. There’s all kind of things that we can correct now just with the lens, by the implant.

So it’s like a Coke-bottle lens inside your eye. Soscia: Right. Think of a cataract as basically being like a little baby contact lens that everyone is born with that just over the years gets thicker. People tend to think of it like a cancer, an abnormal growth, and it’s just really that baby contact lens that you were born with inside your eye that gradually gets a little bit thicker, a little discolored. Certain people get it faster than others. Some people get injuries to their eyes. Some people are on certain medicines or have certain diseases—diabetes, other things like that—that can make that cataract grow faster in the eye and then get really cloudy to the point where no matter what we are doing with our glasses, we just can’t see as well. Dr. Stephenson did a wonderful with the M&M analogy. Pop it out and put the new one in.

What are some of the risk factors with these diseases? Mali: The “big three” risk factors for macular degeneration are advancing age, genetics and smoking. Other things are good diet and regular exercise; UV light exposure is somewhat of a risk factor, but it’s kind of controversial. Newer information shows that blue light in all of our screens does affect retinas in animal studies, so we can infer from that that there may be some impact, especially in patients with retinal problems, that they may be at a higher risk for developing changes with blue lights. I recommend my patients utilize a blue light-blocking filter in their glasses to help prevent that theoretical risk. And light-colored-skinned people have a higher rate of macular degeneration. Stephenson: There is a DNA test you can actually do too, where they take a swab, just like in CSI, and send it off and the patient is evaluated for their risk at two, five and ten years. Then the doctor can determine what supplements should be taken and what kind of follow-up should be done. Soscia: A hobby I do on the side—I’m certified in age management medicine. You can look at every single disease and basically the root of all disease is inflammation. There are so many inflammatory markers even when we just go to a regular physician visit that really don’t get measured. Are you eating well, getting proper rest, proper exercise? I can’t stress that enough to my patients how important it is to live a good lifestyle. Mali: One other way to look at degenerative eye diseases is by systemic association. One big one on my end is diabetes, and diabetic eye disease. Diabetic retinopathy is a large problem in our country, with about 4 million people that have visual loss from diabetes. And that number is actually going to jump to over 6 million in the year 2020 so really diabetes is an epidemic in our country. But we have some great treatments available. There are two steroid implants that are really impressive. One is Ozurdex, this small biodegradable implant that I inject in the back of the eye. Even newer now is an implant called Iluvien—you can fit 25 of them into a single grain of rice and inject that in the back of the eye and it secretes steroid medication over a three-year period to help give patients relief from swelling in the back of the eye from diabetes. I was actually one of the first doctors in the country to use that medication; I was involved in the launch of that medication.

How does somebody know if they have a disease or something like allergies or dry eyes? Mali: It can be very vague, especially with diabetic eye disease. People can have a little bit of blurry vision and they go to their eye doctor and just want to get checked for glasses. The most important thing when you see a patient is to give them the complete eye exam. Check the front and back of the eye and do a dilated eye exam so we’re able to catch things early. Sometimes with the exam, we are able to catch these chronic diseases in the earlier stage to help give the best possible outcome. Soscia: Even dry eye is pretty significant. Oftentimes dry eye can be related to other things like rheumatoid arthritis or Lupus. Diabetes can oftentimes present that way. Stephenson: And then stuff we induce for dry eye. For Glaucoma, all the medication, topical medications, that the patients take can really cause terrible eye dryness and pain. It’s a vicious cycle—one disease can cause another disease. The biggest thing that we can tell anyone is that they need an eye exam once a year after a certain age. I used to say 50; now I say 40 because with computers and hand-held devices and all that stuff, people are getting real fatigue and dry eye symptoms way earlier. We kill off our lacrimal glands early in our life and when you’re 50 and have terrible dry eyes, it’s too late to fix it.

We haven’t had a full generation yet that has been exposed to blue light screens from when they were children—what do you think the effects of this will be? Especially now that people sit in front of a computer or a phone screen for most of the hours in their day. Stephenson: You should have a filter. There are companies that make the filters for your phone and for your computer screen. We know some of the problems that arise, but we don’t know all of them yet. Soscia: Too much of anything is probably not good. That’s number one. Number two, with blue light, there’s actually some controversy on that—blue light is also believed to have some importance streamlining circadian rhythms. But probably too much of it isn’t great. Stephenson: As physicians, we don’t know everything. I have to go read about stuff now when patients come in on a new medication—I used to know all those medications whereas now every day there’s thousands of medications and I’m not quite sure what they all do. Like you said, how do you know what your disease state is? We used to put all the onus on the doctor, to figure out the diagnosis and do the treatment; now we have to put some of the onus on the patient to seek out the medical help and to be responsible for their own health. If they’re going to sit around and be sedentary and eat a ton of sugar so they have to be put on insulin and then have to have injections—they could have done something different by walking or changing their diet: take on some responsibility, too. The whole landscape has really changed. Mali: With degenerative eye diseases, it’s really important to focus not only on treatment but also prevention. For diabetes, you can prevent or even slow down the disease by—another “big three” that I have—controlling your blood sugars, controlling your blood pressure and controlling your cholesterol. There’s actually an eye vitamin available that I recommend to my patients with macular degeneration. Medicare just approved a new device—a home monitor. It helps to monitor patients’ macular degeneration and detects changes and it’s all automated and streamlined. It automatically and periodically documented changes in each eye of my patients that had it, where it actually called me and said, “Ms. Smith had a change in her left eye,” and that’s when I’d call Ms. Smith and say, “Ms. Smith, please come in right away, we’re going to take a look and see what’s going on.” Technology is now catching up with us, not only on the treatment side, but also on the prevention side.  

About Our Participants

William L. Soscia, MD is a graduate of the US Military Academy at West Point. He is a decorated Army officer, serving in the Persian Gulf War in Iraq. Following his military career, Dr. Soscia was admitted to the University of Florida College of Medicine where he graduated with honors in research and was elected to the Alpha Omega Alpha Medical Honor Society. Dr. Soscia has extensive experience in cataract and lens replacement surgery with advanced premium intraocular lenses. He also is experienced in refractive procedures such as LASIK, CK and refractive lens exchange. Dr. Soscia has published numerous papers and has given lectures at national meetings on topics in refractive surgery, as well as cataract surgery and intraocular lens technology. He also serves as a clinical assistance professor at LECOM. Board-certified by the American Academy of Ophthalmology, Dr. Soscia is a member of the American Medical Association, Florida Medical Association, Manatee Medical Society, the American Academy of Ophthalmology and the American Society of Cataract and Lens Replacement Surgery (ASCRS). He has been consistently named a Top Doctor by Castle Connolly Medical.

Joshua Mali, MD graduated from West Virginia University School of Medicine for his medical degree and internship where he was awarded the WV Medical Scholarship Award. He went on to Albany Medical College for his residency in ophthalmology and was elected Chief Resident by his peers and faculty. He also did his medical and surgical Vitreo-Retinal fellowship training at Retina Consultants/Albany Medical College while serving as an assistant professor of ophthalmology. During his fellowship, he became one of the first retinal specialists in the United States to use Iluvien, a new steroid implant for diabetic macular edema. Dr. Mali has published research in esteemed medical publications including JAMA Ophthalmology, Ophthalmology Times and Retina Today. He has presented at national and international research meetings, is the principal investigator in clinical research trials and has given lectures across the country. Dr. Mali has given his time and contributed his medical expertise to worthy organizations such as Medical Ministry International, Georgia Lions Camp for the Blind, Columbia Lighthouse for the Blind and Health for Humanity. He has participated in mission trips all over the world, most recently in Mexico and Nicaragua. Locally, he was a volunteer ophthalmologist for the Remote Area Medical (RAM) organization event in Bradenton, FL that provides free medical care to underserved populations in the United States. He was also a mentor/preceptor for a NASA-sponsored WVU Robotics Team.

P. Dee Stephenson, MD, FACS is the founder and director of Stephenson Eye Associates in Venice, FL. She is a native Floridian who received her BS from the University of Florida, her doctorate from University of South Florida and completed her residency in ophthalmology at the University of South Carolina.  She is a Fellow of the American College of Surgeons, a member of the American Academy of Ophthalmology and certified by the American College of Eye Surgeons (ACES). She has extensive expertise in micro-incisional cataract surgery and implantation of premium intra-ocular lenses, custom Femto cataract techniques and intraoperative aberrometry. She was listed as one of the 250 in Premier Surgeons of Leading Innovators and most recently was named in the Ocular Surgery News Premier Surgeon 300 and Who’s Who in Ophthalmology. She is continuously engaged in clinical research and studies to evaluate new technology and is at the forefront of research and development in the creation of specialized surgical instrumentation and techniques, as well as the development of the next generation of lenses. Dr. Stephenson is an associate professor at the University of South Florida in Tampa. She consults for several major companies in many different roles and is the current president of the American College of Eye Surgeons.