SIGHT, The Story of Vision2

ForewordAugust 25, 2016 The human eye. It has been called the window to the soul. A miracle of nature. A complex organ like no other, focusing and translating the energy of the stars into vivid experiences and priceless memories. SIGHT: The Story of Vision is a breathtaking film, bringing audiences on a remarkable journey in an informative, entertaining and touching manner. Yet it also paints a picture of how delicate our eyesight can be, as millions battle natural occurrences, tragedy and age to preserve this vital sense. For decades, the people of CooperVision have been working to help improve the way people see each day. This clear purpose guides our approach to developing advanced contact lens products, to partnering with tens of thousands of eye care professionals and to committing significant funding for non-profit initiatives that protect and restore sight in communities spanning the globe. It is our privilege to help bring this project to life, in the hopes that you will share our awe of the science, magic 1

and power of sight. Daniel G. McBridePresident, CooperVision, Inc. 2

CHAPTER 2 The SIGHT ProjectThe SIGHT project started as an idea during the making of the film, “400 Years of the Telescope” written and filmed by Anita Ingrao and Kris Koenig, its filmmakers. From Anita’s idea at the beginning of 2014, it developed into a major project under the perseverance of Kris Koenig, David Fleishman MD and Brien Holden OD into a multi-media program filmed on six continents. Its intent is to increase the public’s understanding of sight and, along with other industry and philanthropic initiatives, know the importance of an annual eye exam. The SIGHT Project is:SIGHT, The Story of VisionSIGHT: The Story of Vision, by Koenig Films is a one-hour documentary that presents the science, medicine and technology used to maintain, improve and restore human vision; and the individuals that battle against the darkness of blindness. Every individual will experience an issue with his or her sight in their lifetime and this film shows that we don’t have to suffer with poor or reduced vision. Sir Elton John, the film’s narrator describes it 3

as follows, “This is a story about how our eyes and our brains work, to create the images of the world in our head; and the people that drive the science, medicine and technology that keeps them working for us.”The project and 1-hour documentary for Public TV/PBS and International distribution would not have been possible without Southern Oregon Public Television and the funding in part of the project’s underwriters: Adlens, Alcon Foundation, Brien Holden Vision Institute Foundation, Carl Zeiss Vision International, CooperVision, Costa del Mar, Dante Alighieri Society of Massachusetts, EnChroma, Essilor, Reade Fahs, Dr. David and Jacqueline Fleishman, Eric Fleishman, Dr. Robert and Marcia Fleishman, Dr. George and Rita Foster, Wayne Godlin, Charles Grode, Luxottica, NA, The New England College of Optometry, OneSight Foundation, Opticians Association of America, Opticians Association of Massachusetts, Dave Sattler, ThinOptics, The Vision Council, Vision Service Plan (VSP) and VOSH International. Kris Koenig, SIGHT writer, producer and director with friends at public TV Filmed around the world in brilliant 4K the documentary visits Australia, Vietnam, China, Honduras, South Africa, India, Peru, 4

Dominican Republic, Brazil, North America, and Europe. The film’s score is composed and played by Tran Manh Tuan, a Vietnamese national who attended the Berkeley School of Music on full scholarship and has vision loss in one eye due to corneal disease. The music is a blend of both western and eastern sounds that builds a rich auditory tapestry on which the film floats. SEEING, A Photons Journey Across Space, Time and Mind SEEING is a 22-minute full-immersion planetarium program, narrated by Neil deGrasse Tyson, which uses 4D animations and video to teach how human vision works. The planetarium program is distributed free to 1,500 planetariums around the world through the International Planetarium Society. SEEING is underwritten by a grant from Carl Zeiss Vision. The Companion eBook will provide the text and a downloadable student/teacher guide for schools visiting the Planetarium show will be available from the “Sight” website. For elementary school age children and their parents, Alcon provides the downloadable book, “Howard and the Amazing Eye Exam” for both the planetarium and outreach events, also available in the companion eBook. 5

Second Screen Second Screen is an interactive iOS and Android app for tablet and smartphone that allows access to other SIGHT, subject videos. Pause your TV, watch any or all of the following for a deeper look at subjects highlighted in the film. ECHO Honduras - Cataract Campaign, Dr. Kozarsky, A Short History of Spectacles, The Work of Eye Banks, How Glasses are Made, Eye Mitra/Vision Ambassador Program, Understanding Dry Eyes, Contact Lens Care, Low Vision Care/VA Western Regional Blind Center, Lasik Correcting Vision and Understanding A Cataract Operation. Second Screen and is underwritten by a grant from Essilor.The Story of Sight, Website 6

The website provides a rich overview of the entire project, and access to the many of its component parts. Click the image to visit. SIGHT| The Story of Vision eBookThis SIGHT e-Book provides a deeper dive into the topics of “SIGHT” with extended and in-depth text and video content, from the library of interviews. This eBook is underwritten by a grant 7

from CooperVision.SIGHT Public TV Affiliate, Outreach EventsOutreach events are critical to accessing as many U.S. households as possible with the “SIGHT” message. All across the US, local sponsor’s grants make possible eye screenings, provided by local eyecare professionals. These events deliver face-to-face, information about a person’s vision as well as the eyecare, eyewear and contact lens resources available for good sight and healthy eyes. The local public television station and Southern Oregon Public Television (SOPTV), make possible the eye screenings, eye health fair and a re-screening of the SIGHT documentary. 8

IN MEMORIAM We lost two very dear people during the time we filmed SIGHT. Both were instrumental in the creation of the SIGHT documentary and the overall SIGHT Project. Anita Ingrao, 1963 - 2015Anita Ingrao initially conceived the idea of a documentary about the past, present and future of vision and, gave its first outline life. As filmmaker, writer and editor, Anita provided the ideas and inspiration for the roadmap followed. 9

Brien Holden PhD, DSc, OAM, 1942 - 2015Dr. Brien Holden was a friend and his very big personality was a champion of this project. “Brien was a man of extraordinary vision who devoted himself to the service of mankind. He demanded that the research be indivisible from the service to society. He was truly an intellectual giant in eye health and vision, a powerhouse driving change by mobilizing teams globally united in science and service to the disadvantaged of our world”, Kovin Naidoo, OD, CEO Brien Holden Institute Preface 10

Mark Mattison-Shupnick, BA, ABOM, Director, Education, Jobson Medical Information LLC, Author, eBook “I’m pleased to have been a part of the Advisory Committee for the SIGHT documentary and asked to stitch together, in an eBook, a deeper look at SIGHT, The Story of Vision.Through the transcripts and film clips, of the many extraordinary people interviewed, we hope that you learn the complexity of vision, the variety of vision problems, the importance of an annual eye exam, the joy of beautiful eyewear, the freedom of contact lenses and the enormous need for better vision around the world.Since this book uses transcripts to tell a story, imagine that, that person is talking to you, telling the story in their own words. Juan Batlle, MD, Director Centro Laser, Santo Domingo, i think, reflects the feelings of so many of those dedicated to the production of this film. He said...“Well I think that everybody should care about eye care, about the rest of the world. We are an alliance of people. There is one planet, there is one world, there is one atmosphere that we share. There is one ecology that we can protect. The forest that we burn in Brazil 11

affects the oxygen that we consume in the United States. The water that we contaminate in one area, they have to be used by the fish that we made a living out of and we eat them and we get contaminated. Likewise, when human beings are going blind elsewhere in the world, what are they doing? They are suffering, they are becoming dependent, they are struggling, their economies gets weakened, they are not able to study, they are not able to learn. When we help them, when we make them see better, when we demonstrate our solidarity, they are going to be grateful, they are going to be part of that alliance of people and we are all going to feel good about doing it. And I know, personally, that when I help someone I don't need to be paid, just the fact that they are grinning and able to see and tell me how much life has changed that is enough for me to make me happy. And I think that happiness has to be shared with others through your eye documentary.” FUNDING FOR SIGHT The project and 1-hour documentary for Public TV/PBS and International distribution would not have been possible without Southern Oregon Public Television and the funding in part of the project’s underwriters: Adlens, Alcon Foundation, Brien Holden Vision Institute Foundation, Carl Zeiss Vision International, CooperVision, Costa del Mar, Dante Alighieri Society of Massachusetts, EnChroma, Essilor, Reade Fahs, Dr. David and Jacqueline Fleishman, Eric Fleishman, Dr. Robert and Marcia Fleishman, Dr. George and Rita Foster, Wayne Godlin, Charles Grode, Luxottica, NA, The New England College of Optometry, OneSight Foundation, Opticians 12

Association of America, Opticians Association of Massachusetts, Dave Sattler, ThinOptics, The Vision Council, Vision Service Plan (VSP) and VOSH International.DISCLAIMER: This eBook is a companion piece to the film SIGHT, The Story of Vision. The information and short videos contained in this book are not intended and should not be construed as medical advice and does not replace the need for an annual eye exam. The views and opinions expressed are solely those of the original authors and other contributors and not those of any of the SIGHT project underwritersCOPYRIGHT 2016, Koenig Films, Mark Mattison-Shupnick, all rights reserved. 13

CHAPTER 3 The Science of VisionSight is arguably our most important sense. An extremely complex process, which requires light that can start with photons, generated in distant stars and ends in the visual cortex of our brains... in the middle of this process, our eyes. Sight is adaptive, and, in humans it develops during our first decade of life. ALL THAT VISION ENCOMPASSES 00:00 / 00:00 From the opening of the documentary SIGHT|The Story of Vision, narrated by Sir Elton John. 14

(Adapted from Embryonic Eye Development, Linda Conlin, 20/20 Magazine Dec 2012)“Even after nine months of simultaneous, rapid-fire tissue formation, the eye is not mature at birth. A newborn’s eye is about two-thirds (65 percent) of its full size, so the eye must undergo a series of changes that can take as long as a year.The changes include growth of the orbit, changes to the crystalline lens and final maturation of the macula, as well as pigmentation of the iris. Horizontal, vertical and rotational eye movements are somewhat uncoordinated and develop at different rates. On the neural level, receptive fields of the retinal ganglion cells are smaller in infants. Many cells in the lateral geniculate nucleus (LGN), part of the pathway between the retina and the visual cortex, do not yet respond to visual input. Because of an undeveloped ability to accommodate (see up close), visual acuity in infants is about 20/400, which results in a focal distance of 8 to 10 inches. Acuity improves to 20/25 at about 6 months of age. This process is called ‘emmetropization’ (20/20 vision). Corneal curvature also changes after birth. The brain’s accurate interpretation of visually transmitted images seems to take a little practice. Spatial orientation of images takes even longer because stereoscopic vision doesn’t fully develop until 15 to 18 months of age. It is normal to find low levels of hyperopia (far sightedness) in infants. Hyperopia greater than 3D occurs in 25 percent of 15

newborns. Refraction of 4D is found in 9 percent of infants at 6 months. By 7 to 9 months it falls to 5 percent and continues to decline to 3.6 percent at 1 year of age. The incidence of astigmatism decreases from 1.5 to 3 years of age as the cornea flattens. Instances of anisometropia, different refractive errors in each eye, are common at birth but decrease quickly with age. If all the components of the eye grow proportionally, any refractive error decreases. Myopia (near sightedness), however, seems to rebound. As is the case with hyperopia, infants born myopic will become less so. However, the tendency is for myopia to increase into the higher ranges once the child begins school.” (Adapted from Embryonic Eye Development, Linda Conlin, 20/20 Magazine Dec 2012)EVOLUTION OF THE EYE Ivan Schwab, MD, Professor of Ophthalmology, University of California, DavisDr. Schwab remembers asking the question, “how did camels go so long without drinking?” That questioning mind, his ophthalmological training and ornithologist wife, “...led to interest in how comparative ophthalmology, comparative optics and comparative physiology is applied and done. You can't ask those questions without beginning to say, how did it get this way? How is it that one eye can be so different from another and yet fits the niche of the animal perfectly? So that lead me to the evolution of 16

the eye.The brain does have a series of layers. Some of those layers are stable and you can almost extinguish it i.e., get rid of that image by allowing it to sit on the brain for awhile. You only have to stare at an object singularly for several seconds, minutes and it'll disappear. So, there is a layer of background and then movement is often super imposed and color is super imposed on that. This is how we put an image together. It isn't just as simple as having the signals go to the back of the brain and those signals being compared. It then goes through another process where this layering occurred. Very much like a color plate series in forming images for color pictures used to be, Now they are digital.We're a primate. Primates have an excellent visual system but it's not the best and some of the complexities that occur in our eye are out done by other species, birds for example. Birds see better detail, they see more colors than we do. They do more with their vision than we do and we don't understand it completely, not even a beginning really of how birds do this better then we do. So, it is a very complex system in humans but it is even more complex in birds. And, there are some special animals that see even more than birds do. The one I'm fond of is called the mantis shrimp. The mantis shrimp sees with twelve or sixteen different visual pigments. We don't know exactly what it does with all this information but compared to our three visual pigments (and a mantis shrimp with twelve to sixteen visual pigments), imagine the different array of colors that this brain has to work with in seeing it's surround. So yes, we have a very complex system. It works intricately and is really quite good among the animal world but it's not the best and if you think about it each animal has it's own eye to fit the niche that it lives in perfectly. Evolution created the eye in all species to fit the niche that it occupies. And, it does so by finding a solution that allows it to 17

compete with it's fellow competitors or it's fellow species so that it's succeeds where others don't. It's all about competition. The other thing that is key to understanding how evolution does this is to understand deep time. Meaning that this doesn't occur over a few years or a thousand years or ten thousand years. It occurs over millions of years with little bits of changes over a long period of time. Time that we really can't wrap our brain around to understand. The way this works is that evolution will find a little bit of an advantage for one species over another and that species will be successful whereas the species that doesn't make that change often fades away and is lost. In fact, 99 or greater percent of animals that have lived on earth before, are gone. And the reason is that they have been out competed or they have lost their lives from comet strikes or what have you. But, the animals that have succeeded and the visual systems that have succeeded have been those that match the niche that the animal lives in the best.” 18

Our eyes are really extensions of our brain. They’re delicate orbs that are formed of both transparent and opaque cell-structures, nourished by tears and blood, moved by micro-muscles, with a lens for focus, photo- reactive cells to capture photons, all connected by a vast network of neural fibers that all work in unison, to transmit the data carried by photons, to our brain. 19

Structures Of The EyeEYE ANATOMYIt’s helpful to know the major structures of the eye for discussions about sight. In this cross section of the eye the parts are labeled. Each of the numbered parts has a description below.1. The LID, contains the lashes that protect the eye from dust and debris, inside is a gland that produces an oil as part of the tear layer2. The CORNEA, the clear window at the front of the eye3. The SCLERA and notice that the sclera is continuous with the cornea and the optic nerve4. The covering of the OPTIC NERVE. These structures make up a complete outer yet very specialized covering of the eye.5. Once light passes through the cornea, it enters the ANTERIOR CHAMBER, the space in front of the iris and behind the cornea, 20

which contains water like liquid called aqueous humor6. The PUPIL; the space through which light continues to the retinaThe IRIS regulates the amount of light that gets to the retina“The iris has an aging process because when you are young it can go over 6, 7 millimeters and then when you get older it stops around 3mm. The fact that the iris changes size with aging is a problem for the cataract surgeons because of course we have to dilate the pupil in order to remove the lens that has become a opacified and this is a problem, it's also the reason older people, in spite of the eye glasses and all the peripheral correction that they may have, they do not see as well as someone who's a lot younger.” Juan Battle MD 8. The RETINA, here the yellow innermost layer of the back of the eye9. The OPTIC DISC or nerve head where the nerve fibers exit the eye. It is also the pipe that contains the blood vessels that enter to nourish the inside of the eye10. The middle layer, the CHOROID, the blood vessel layer11. The FOVEA – the point of best vision in the center of the macula. When reading the word fovea, there’s a straight line from your own fovea to the word. When you look directly at an object – you are pointing your eyes so that that object is focused onto your fovea.12. VITREOUS - The clear jelly encased in a membrane that is called the vitreous humor. In fact, this space at the back of the eye behind the lens is called the vitreal cavity.The CRYSTALLINE LENS and with the cornea helps to focus light onto the retina for crisp visionSTRUCTURES OF THE EYE 21

00:00 / 00:00 From SEEING, A Photons Journey Through Space, Time and Mind, narrated by Neil deGrasse TysonDid you know?The average person blinks about 10 times a minute When reading or concentrating, blinking slows to 3-4 times a minuteInfants blink only 1 or 2 times a minute Pupil size varies from about 2mm to 6mm, larger when you are youngerPupils get bigger when you are frightened or see something of interestPupil size decreases with age, that will be an important consideration for how comfortable we are in dark sunglasses as an older adult 22

THE RETINAThe retina is an amazing structure, made up of the same types of cells as the brain. As we said, it’s really an extension of the brain. Its job is to receive light for vision as well as manage a variety non-optical functions like sleep patterns, alertness and a feeling of well-being. In the illustration of the retina is called a ‘fundus picture’. Starting on the left, the peripheral retina is made up of rods; receptors for vision in dim light and at night. The macula has a concentration of cones, the receptors for detailed and daytime vision. From Dr. Smith PhD, “Our retina has two types of photo receptors called rods and cones. There are actually three types of cones, the short, medium, and long wavelength cones, which very roughly correspond to blue, green, and red colors. We perceive the different colors in the world, essentially the same way that colors are made on a computer monitor. There's different lights that are shown ... Red, green, and blue. Different mixtures of those produce all the different colors that we can see. There's other species, other animals, that have more types of cones and they can see even richer in color space than we can. We see a very 23

rich colorful world as it is. Rods are a different type of photoreceptor. They're sensitive to low levels of light. So actually, when we're out at night, if you notice you don't see color very well in the dark or in very dim light. That's because the cones don't have enough light to see, and the rods are the ones that are active. The rods and cones are actually distributed differently across the retina. You have the highest amount of cones in the very central part of your vision exactly where you're looking. This allows us to perceive all the rich colorful information that we get by moving our eyes around and sampling from place to place. We have more rods in the periphery. This is the source of a common phenomena that people can see when they look outside ... if you look up in the dark at the star lit sky, you often will see a dim star. You look at it and you actually think that it goes away. You look around, and you look a little bit away from it and you can see it again. This is because we don't have rods in our central vision. We have only cones. Only color vision. When you look at a very, very dim object, you actually can't see it because there's this little hole in your vision for seeing dim things. These different types of photoreceptors, these rods and cones, process different types of information. As I said, color versus low intensity or dim things, and they're useful for different types of vision. Seeing in the dark versus seeing highly detailed bright things. That information, from the different photoreceptors, gets passed on to our brain. In fact there's different parts of the thalamus, this relay station in the cortex, that process color and non-color information to different parts of our primary visual cortex. That information does stay somewhat segregated on the way to the brain. However, as we move into the cerebral cortex, this type of information has to be combined. So for instance, if you're looking for someone in a crowd and your friend is running, and maybe they're wearing a red shirt ... You 24

need to detect a moving thing that might also have a certain color. We need to recombine that information. That's part of what the circuitry of the brain does, is take these certain pathways, different colors and non color, dim and bright information, and recombine them into the perception that we have.”RETINAL LAYERS Three layers of the retina that process light in the form of photons and wavelengths for night vision, day vision and color.The complexity of the retina is fascinating. In a simple sense it is made up of three layers, the ganglion cell layer, bipolar cell layer and the deepest layer that contains the rods and cones. The ganglion cells use longer wavelength blue light to tell the body when to produce melatonin, a hormone used by the body to regulate sleep patterns. These ganglion cells also use light to help regulate serotonin production, a neurotransmitter that helps to synchronize cells throughout the body. This means that light is not used just for seeing. 25

The bipolar cell layer provides communication connections for the rods and cones to the ganglion cells and then to the nerve fibers at the top of the retina that transmit electronic signals to the brain.As we learned, rods are very sensitive to small amounts of light and therefore provide vision in dim light and at night. This sensitivity to light provides cues to motion in our peripheral vision. That was a good thing for early man, it probably kept them from getting eaten by the animals around them. The cones, however, need much more light to function. They provide our ability to see acute detail of objects that are near or far away as well as color vision.Color is the sensation we experience when the three different cones are stimulated by light, convert that light to an electro-chemical signal and send it off to the brain for interpretation. There is also a bit of crosstalk as the signal is passed through the bipolar cells, almost like the cells are a committee of cones, bipolar cells and ganglion cells deciding the form of signals to send. When cones lose sensitivity to certain wavelengths, genetically or from old age, disease or medications, we say that those individuals are color vision deficient (CVD), usually referred to as colorblind.Blood vessels lie on top of the retina and provide nourishment, oxygen and carry away wastes.The optic nerve head is the place where the nerve fibers and blood vessels enter/exit the eye to the brain. It is also known as the blind spot. Because we use two eyes together, we rarely notice it. One eye’s visual field overlaps the other and fills in vision for that eye’s blind spot.There two more systems that we should look at before we look at the interaction of the systems for vision. 26

EYE MOVEMENTThere are six ocular muscles that move each of the eyes. Now work your eye muscles – turn your eyes up, down, right, left, up and to the right, down and to the left. Look away from the computer or tablet across the room, then back down at the screen. Your brain controls all of those movements. The muscles smoothly look where you ‘asked’. Amazing. Juan Batlle, MD, Director, Centro Laser, Santo Domingo “Now, in the eye there are six muscles that are responsible for it's 27

movement. There are two that go in and out, in medial rectus and lateral rectus that are two that bring it up superior rectus and inferior rectus. But then there are also two that rotate it. Superior oblique rotates it in and inferior oblique rotates it out. It is the action of the 6 muscles that is responsible for ability to move the eyes to one side to the other and this ability is perfectly synchronized with the brain. Not only is it synchronized for one eyeball it's synchronized for both eyeballs looking exactly at the same target. The computer up there (your brain) that is running and coordinating the eyes is phenomenal. If I tilt my head there is an immediate message to straighten the eyeball so that I can continue to have my eyes on sight as it were a gyroscope on a ship so that whens it's moving in the waves you are still able to compensate. TEARS AND THE LACRIMAL SYSTEMThe lacrimal or tear gland makes it ‘rain’ over your eye through the openings in the top lid. This liquid forms the middle of the tear layer. Each time you blink, tears are distributed towards your 28

nose. With the blink, the puncta opens so that the tears drain into the canal. Next time in front of the mirror, look for the lower puncta drain hole in your lid. Tears collect in the lacrimal sac and drain down the lacrimal duct into the back of your throat. The sac helps equalize the pressure of each blink so the tears flow smoothly.Did you know?Dry eye is common among older adults (goto DRY EYE for more information).During the sixth week of gestation, the lacrimal glands begin forming but produce no tears until the third month after birth. That Is why infants shed no tears when they cry.A newborn’s eye is about two-thirds (65 percent) of its full sizeThe eye undergoes a series of changes, growth of the orbit, changes to the crystalline lens, final maturation of the macula and pigmentation of the iris and that can take as long as a year.RESOURCES All About Vision, Eye Anatomy, Parts of the Eye CooperVision, Eye and Vision WebMD, Eye Health Center AOA, How Your Eyes Work 29

Vision, The Way We SeeMatthew Smith, PhD, Assistant Professor of Ophthalmology, University of Pittsburgh Medical Center“A lot of people think that a good metaphor for the brain is a camera. On the surface that seems actually quite apt. The camera has a lens that focuses the light that comes in from the world, it lands on a sensor which converts that light into electricity and gets stored as digital images, and our brain and eyes are much like that in a way. We have a lens in our eyes and a cornea that focuses that light onto our retina…” Dr. Smith and Dr. Juan Battle explain vision; touch the image to start the video.THE CAMERA AS A METAPHOR 30

00:00 / 00:00 Matthew Smith, PhD, Assistant Professor of Ophthalmology, University of Pittsburgh Medical Center and Juan Batlle, MD, Director, Centro Laser, Santo Domingo describe how the eye focuses light. Dr. Smith goes on to say, “… I study the cerebral cortex, or the covering of the brain, which contains neurons that are responsible for all sorts of higher order functions, perception, and cognition. Our visual cortex actually makes up more than half of our cerebral cortex. Primates are very visual animals. This half of the cortex is actually subdivided into many different regions. It depends on how you want to categorize it, but there are more than 30 different regions of the brain that are responsible for different types of visual processing. One categorization that some people have proposed, as a good one, is that there's a dorsal and a ventral stream. People call this ‘the what’ and ‘the where’ pathway. The what pathway takes information about what an object is in the world. So, what it's color is, what face you're seeing, what shapes you're seeing, and defines those features in an object. The where pathway helps you identify where something is in the 31

world and where it's going, such as you're walking down the street and a car drives by you and you need to track where it is so you can stay out of its path. These two pathways of the brain are one way people have thought is an easy way to categorize the different functions of these different brain regions. That's been useful for many, many years in pushing forward our research on the brain. However, what we've learned over time is that it's sort of an oversimplification. The brain is a very richly recurrently connected device, so to speak. All of the different regions of the brain, both between what people thought of as these different pathways are actually communicating very actively with each other all the time. So information arrives into our eyes at the speed of light, of course. Then once the information hits our photoreceptors, the cells that sense the light, convert it to an electro-chemical signal. Within a neuron, between the cell body and the synapse the information travels electrically. However, to get to the next neuron it needs to be converted to a chemical signal. Neurotransmitters, which are a type of chemical that signal between cells, go across that little space called the synaptic cleft. That neurotransmitter signal tells the next cell to be active or not active. The information as it goes, takes a little bit of time. It goes very fast from one cell body to the synapse, then a little bit slowly and noisily over the synaptic cleft. To get from the retina, the outside of the first neurons that are sensitive to light, and to the brain ... It takes maybe 20 or 30 thousandths of a second for that information to be processed. We know that in humans, we can make choices. There's been research showing that you can, for instance, tell between an animal and a non-animal. If you get a very rapid picture, and it's shown and then taken away very quickly, you can tell within a couple hundred milliseconds, which is to say 2/10 of a second, whether this was an animal or not. You can make very quick rapid discriminations between what's out there in the world because 32

our brains operate so quickly. However they are fundamentally limited by this conversion between electricity and chemistry as the information travels along those inferences.”The following animation is about the process of vision as light, in the form of photons, as they hit the retina and are converted to an electro-chemical signal for interpretation by the brain. From the planetarium show, SEEING, A Photons Journey Across Space, Time and Mind, narrator Neil deGrasse Tyson begins with, “…The photon’s journey will end here at the retina but not the data it possesses. The data are made up of the color and intensity of the original source, the star, more than 1000 light years away. The job of the retina is to encode the data in a way that the brain can interpret it…” Touch the image to start the video. THE JOB OF THE RETINA IS TO ENCODE THE DATA 00:00 / 00:00 From SEEING, A Photons Journey Through Space, Time and Mind, narrated by Neil deGrasse Tyson Color evokes emotion and our rich world of sight is enriched by 33

the colors we see. Color, as we’ve learned, is a function of the cones. Watch and listen again to Neil deGrasse Tyson describe the connections made by cones located in the fovea. “Each of the three cones transmits a specific color based on the three pigments they contain.” He then describes the ganglion layer to understand the path of the photon and electro-chemical reaction.”THE ACTIVITY OF CONES 00:00 / 00:00 From SEEING, A Photons Journey Through Space, Time and Mind, narrated by Neil deGrasse Tyson This layer is “…the farthest extension of the brain and the only part of the brain that is visible without invasive surgery. The retina has often been called the window to the soul. That’s because many of the changes to the body due to disease are first seen as changes to the retina.” Clearly, that suggests a visit yearly to an eyecare professional. Ophthalmologists and Optometrists, who specialize in the eye, can detect diseases like Type 2 diabetes, long before other methods just by observing the retina. 34

To continue our journey, what are the connections made by the various retinal cell layers? How does the information travel to the brain? In this segment from SEEING we will see how complex the process of changing light to visual information that you can use. In fact, vision requires an estimated half of the brain’s resources. VISION USES HALF THE BRAIN’S RESOURCES 00:00 / 00:00 From SEEING, A Photons Journey Through Space, Time and Mind, narrated by Neil deGrasse Tyson Now we are better prepared to understand the next section, the conditions of the eye that may blur or destroy vision. 35

Joseph F. Rizzo III MD, Professor of Ophthalmology, Harvard Medical School, Director of Mass. Eye and Ear’s Neuro-Ophthalmology ServiceFROM A NEURO-OPHTHALMOLOGY POINT OF VIEWIf there's a visual problem, it could be either in the eye or in the visual pathways within the brain. Neither ophthalmology nor neurology as specialties are well suited to span the full range of problems that can disrupt vision. Neuro-ophthalmologists have this unique position of straddling these two specialties and being able to make diagnoses about changes in vision regardless of whether the problem is in the eye or the brain.To answer the question of how the brain creates vision images, I'll begin by saying we really don't know. There's a lot information that's developed since some groundbreaking Nobel Prize winning work by Hubel and Wiesel. They laid out a schema which seemed to make sense. There was a very orderly representation of the pixels within the visual world in the anatomy of the visual part of the brain, and that certain features particularly lines were very stimulating ... lines in particular stimulated certain cells in the visual cortex. You could begin to understand from their work how the brain could assemble an image based upon the contour of lines in the visual 36

scene. Each pixel would recognize special features, and then it was understood that the brain would have to amalgamate or bring these together so you would have an even picture of what you were seeing.We now know that there are many different areas of the visual cortex. There are processing elements that are hierarchical. Basic functions occur, then more specialized functions occur, and that's passed to a different area of the brain. We know that certain visual features like objects and faces are represented in one part of the visual brain whereas images that move or have high contrast are represented in a different part of the brain. It's a very, very complex structure.We don't know yet how this all gets stitched together into a nice seamless image of the visual world, but it has been a wonderful several decades of discovery. Part of the information from those discoveries is really what enabled the idea of how to think about building a visual prosthesis.HOW DO BLIND PEOPLE SEE? While cruising You Tube for interesting additions to demonstrate the wealth of information about sight online, we found Tommy Edison, a muse to help us understand sight from the other perspective. As Tommy suggests in this video, unlike a sighted person, he has no problem in the dark. Click on the image of Tommy Edison to see more. 37

The 3 O'sOPTICIAN From the OAA website, “An Optician is a vision expert; a health professional specially trained to supply, prepare, and dispense optical appliances through interpretation of written prescriptions. An Optician is an integral part of the vision care experience that adheres to exacting standards in order to enhance your vision.Opticians finish and fit eyeglass lenses, frames, and contact lenses. An optician turns your doctor's prescription into the glasses or contact lenses you need to make your vision the best it can be. An optician may also dispense low vision aids and artificial eyes.” For more information see Many opticians are certified as dispensing opticians by passing a national exam and conmpleting continuing education courses to maintain that certification. The “American Board of Opticianry (ABO) and the National Contact Lens Examiners (NCLE) are national not-for-profit organizations for the voluntary certification of ophthalmic dispensers. ABO, the American Board 38

of Opticianry, certifies opticians those who dispense and work with spectacles. NCLE, the National Contact Lens Examiners, certifies those ophthalmic dispensers who fit and work with contact lenses.’OPTOMETRISTFrom the American Optometric Association website, “Doctors of Optometry (O.D.s/optometrists) are the independent primary health care professionals for the eye. Optometrists examine, diagnose, treat, and manage diseases, injuries, and disorders of the visual system, the eye, and associated structures as well as identify related systemic conditions affecting the eye.• Doctors of Optometry prescribe medications, low vision rehabilitation, vision therapy, spectacle lenses, contact lenses, and perform certain surgical procedures.• Optometrists counsel their patients regarding surgical and non-surgical options that meet their visual needs related to their occupations, avocations, and lifestyle.• An optometrist has completed pre-professional undergraduate education in a college or university and four years of professional education at a college of optometry, leading to the doctor of optometry (O.D.) degree. Some optometrists complete an optional residency in a specific area of practice.Optometrists are eye health care professionals state-licensed to diagnose and treat diseases and disorders of the eye and visual system. ParaOptometric From the AOA.org website, “The Certified Para Optometric (CPO trademark) typically carries out a wide variety of front desk procedures such as scheduling appointments, recalling patients, handling insurance forms, accepting payments, and screening telephone calls. They may also be trained in the different styles of 39

eyewear, frame repair and adjusting, office materials purchasing and other duties of a non-technical nature.” For more information, seeOPHTHALMOLOGISTFrom the American Academy of Ophthalmology website, “An ophthalmologist is a medical or osteopathic doctor who specializes in eye and vision care. Ophthalmologists differ from optometrists and opticians in their levels of training and in what they can diagnose and treat. As a medical doctor who has completed college and at least eight years of additional medical training, an ophthalmologist is licensed to practice medicine and surgery. An ophthalmologist diagnoses and treats all eye diseases, performs eye surgery and prescribes and fits eyeglasses and contact lenses to correct vision problems. Many ophthalmologists are also involved in scientific research on the causes and cures for eye diseases and vision disorders.”Ophthalmic Medical AssistantThese technicians work in the ophthalmologist's office and are trained to perform a variety of tests and help the physician with examining and treating patients.Ophthalmic Technicians/TechnologistsThese are highly trained or experienced medical assistants who assist the physician with more complicated or technical medical tests and minor office surgery.Ophthalmic Registered NurseThese clinicians have undergone special nursing training and may have additional training in ophthalmic nursing. They may assist the physician in more technical tasks, such as injecting medications or assisting with hospital or office surgery. Some 40

ophthalmic registered nurses also serve as clinic or hospital administrators. For more information, see 41

CHAPTER 4 Ultraviolet Radiation, Light, Blue LightDid you know that worldwide, 3.2 million people go blind due to prolonged UV exposure every year? In fact, the sun is the greatest environmental factor that contributes to cataracts, the leading cause of blindness in countries where cataract surgery is not available. 90% of skin cancers occur on the head and neck area. This kind of UV damage over a period of time cannot be repaired without cataract, cryo-, Mohs or other types of surgery depending on age, depth or significance of the damage.These concerns are not just on a sunny day either. Overcast skies still allow 31% of the solar radiation to reach the earth, so eyes need protection on cloudy days as well. Moreover, kids receive 3 times the annual sun exposure of adults. As a result, we need to teach children early (and mom) the importance of wearing sunglasses – just as we teach them to brush their teeth and wear a seatbelt, so that they develop good habits, that last for life.WHAT SHOULD YOU KNOW?The sun provides sunlight that is composed of invisible and visible radiation. For our eyes, we are concerned about the effects of the invisible ultraviolet radiation (wavelengths of 215-380 nanometers) and more recently, the effects of high energy visible blue light (wavelengths 415-455 nanometers). The rest of the 42

visible spectrum provides the source for the way that we see and see color. As a result, there is beneficial and eye damaging rays from the sun.ULTRAVIOLET RADIATION UV radiation cannot be seen or felt. While most people recognize the connection between sun exposure and skin cancer, less than 1 in 3 Americans realize the hazards of UV exposure to the eyes. Additionally, only 24% know that UV exposure can cause cataracts. Do these numbers seem correct? Unfortunately, they are. Therefore, become educated about ultraviolet radiation and sunwear. Premature aging is another result of too much UV since UVA are the aging rays. It is estimated that 90% of the premature aging around the eyes is caused by UV damage. Add it up, great sunglasses every year can be a lot less expensive than Botox. 43

Holly Rush, former President, Luxottica Wholesale, N.A.“So the purpose behind what we do, it's not all fun and fashion. There is a real medical need, a necessity to raise the level of awareness for why glasses are important, and why protecting the eyes is absolutely critical. And one of the greatest causes that we believe so strongly in is the protection of eyes, your most vital organ, from UV damage. When we think about the education awareness that's been built in other industries, for example, cosmetics with sunscreen... There's a heightened level of sensitivity of awareness by consumers today that you don't go outside, when the sun is shining, without a proper SPF, you certainly don't send your kids to the beach without wearing sunscreen. But it's interesting to note that only 20% of children are protecting their eyes from, parent’s standpoint, from the harmful glare and rays of the sun. So, we have an obligation as an industry to raise the level of awareness and know how and the importance of protecting the eyes from the harmful UV rays. UV damage does a tremendous amount to impact the eyes at a very young age. About 85% of all the damage you do is done before the age of 10 and that exposure to UV can cause cataracts, macular degeneration, and many other cancers that are formed in the eye. And that's something that most parents, and most people today aren't aware of. So, they choose cheaper sunglasses if they wear glasses at all and we believe that quality matter. Quality frames and quality lenses to protect the eye. 44

There is so much our industry does to promote education and awareness for healthy eyes, and protecting the eyes against UV damage. That is just one of many education messages that we have an obligation to share with the general public, to prevent blindness from occurring and the early onset of eye related disease. But, it goes way beyond that and I like to think of children as sort of the next generation of opportunity, Today as a society, as a population, we don't think to bring our children before they enter school for a comprehensive eye exam and the impact of not doing that has many many consequences to us as a society. Whether it's, you know, learning disabilities, or social and psychological challenges down the line, these are very very near and dear causes to us, many of us in the industry. We can have an impact.” EYEWEAR TODAY IS NOT JUST ABOUT VISION 00:00 / 00:00 Howard Purcell OD, Sr. Vice President, Customer Development Group, Essilor explains that eyewear’s job in protecting the eye from ultraviolet radiation.THE VISION COUNCIL, UV AWARENESS 45

Ultraviolet (UV) light is an invisible, electromagnetic radiation. Your exposure to UV rays comes primarily from the sun, even on a cloudy day. The sun emits UV rays, and unprotected, prolonged exposure can cause serious vision problems. Many Americans may not understand the dangers of UV exposure and take needless risks with their eyesight. The Vision Council's VisionWatch survey of more than 10,000 adults shows Americans are concerned about potential eye problems from the sun's UV rays, yet they have a passive relationship with UV-protective sunglasses. The findings, detailed in our latest report, \"Spare Your Sight: Using Shades for Protection and Style,\" show: Only 31% protect their eyes with sunglasses every time they go outside. 34% have experienced symptoms of prolonged UV exposure, such as eye irritation, trouble seeing, and red or swollen eyes. When it comes to buying shades, more people are concerned with fit (65%) and affordability (54%) than UV protection (44%).Further, many Americans (39%) only reach for their sunglasses when they are outside for two or more hours, but UV damage can start in as little as 15 minutes. It's critical to know the harms of UV radiation and solutions for protecting our eyes no matter the season, location or activity. Sunglasses, the unsung hero of American accessories, are essential for maintaining healthy vision 46

and looking great outdoors (TheVisionCouncil.org). HIGH ENERGY VISIBLE, BLUE LIGHT There’s been a lot in the news and scientific journals recently about the potential damage that blue light can do, over a lifetime, to the eye and/or how new electronics and lighting pose a risk. Blue light is a complex subject and while you want to know all the important things about blue, it’s not all bad.BLUE LIGHT CONCERNS CAN BE HELPED WITH EYEWEAR 47

00:00 / 00:00 Something more recent is the concern about blue light but some of blue light is harmful, other beneficial. As a result, new lenses separate the two to the wearer’s advantage.First, blue light provides a rich mixture of colors in our world. Crayola reports that blue is their most popular color. However, these wavelengths also produce energy. The high-energy visible radiation (HEV), also known as the short blue violet wavelengths, between 415nanometers and 455nanometers (nm), have been associated with retinal problems and age related macular degeneration. The wavelengths 460 nanometers to 500nanometers have a number affects that are beneficial to the body. For example, the wavelength 485nm is associated with good mood and alertness.Our body uses blue differently, day and at night. In vision blue wavelengths are used by the Optic Tract, the cones of the retina to form electric pulses interpreted by the brain as color. The other is the Retina-Hypothalamus Tract (portion of the brain producing essential substances), where the ganglion melanopsin cells use long wavelength blue light to regulate sleep as well as serotonin production. As a result, we have blue divided into potentially 48

harmful and beneficial wavelengths. CONTEMPORARY BLUE LIGHT CONCERNS The Vision Council released a report in Jan. 2016 titled, “Eyes Overexposed, A Digital Device Dilemma” (visit www.thevisioncouncil.org for a downloadable copy). It provides an excellent review for both the office and your patients of the contemporary advantages of our digital world and the vision issues faced by a connected population. In it, it describes a concern about high-energy visible (HEV) blue light and how that might be exacerbating concerns about AMD because of our patterns of use of electronic devices.Let’s take a look at two excerpts from the report to frame our discussion. First, “A combination of factors including the proximity, at which we view digital screens, the frequency and length of time of this use, physical responses to screen habits, and exposure to high-energy visible (HEV) or blue light, have conspired to cause visual discomfort in 65 percent of Americans (VisionWatch 2015). This stress and strain, combined with other physical discomforts, is called digital eye strain.”Next, the report starts the section on the effect of blue light damage as follows: “Virtually every digital device, as well as light emitting fixtures and appliances including fluorescent lamps, has light emitting diodes (LED) that radiate blue wave-length light. Emerging research suggests cumulative and constant exposure to the blue light emitted from backlit displays can damage retinal 49

cells. (From Photochemistry and Photobiology. “Effects of Light-emitting Diode Radiations on Human Retinal Pigment Epithelial Cells In Vitro.” March 2013. As the report teaches, discomfort and the symptoms of blurred vision and fatigue are, of course, temporary. The report effectively describes ways to reduce digital eyestrain with proximity, frequency, time used and general body posture recommendations as well as getting unplugged, as unlikely as that may seem. The report then highlights what is not temporary… “…preliminary research points to a potential long-term hazard from the effects of too much screen time: consistent exposure to HEV, or blue light, may be linked to long-term vision issues such as age-related macular degeneration (AMD) and cataracts (From Experimental Eye Research. “Transmission of Light to the Aging Human Retina: Possible Implications for Age Related Macular Degeneration.” December 2004.Blue light has also been shown to affect sleep patterns. From an original research article in Frontiers in Public Health (13 October 2015), titled, “Bigger, Brighter, Bluer - Better?” (the authors (Paul Gringras et al) describe the testing of a variety of current light-emitting devices and the resulting adverse effects on sleep. The authors write, “Since this type of light is likely to cause the most disruption to sleep as it most effectively suppresses melatonin and increases alertness, there needs to be the recognition that at night-time “brighter and bluer” is not synonymous with “better.” While blue light, high-energy visible radiation is of concern for electronic device use, that same radiation is also part of sunlight in our everyday outdoor environment. And, like UV radiation, the effects of HEV can be accumulated in retinal tissue. That suggests we consider outdoor methods to effectively reduce these hazardous wavelengths as well as reduce potentially hazardous HEV wavelengths indoors and at night. (Blue Light Radiation, A Material Solution, Mark Mattison-Shupnick, 20/20 Magazine, Mar 2016) 50