SIGHT, The Story of Vision2

BLUE LIGHT CAN AFFECT SLEEP AND DIGITAL EYESTRAIN 00:00 / 00:00 “We know that digital eyestrain has surpassed carpel tunnel syndrome...” Alan Burt, Senior Projects Manager, VSP Optics Group. “UV and blue light protection in eyewear and sunglasses, like seat belts in a car, only work if you use them.”OPPOSING POINTS OF VIEW ADVANCES SCIENCEIvan Schwab, MD, Professor of Ophthalmology, University of California, DavisWe asked Dr, Schwab, “Does blue light cause damage to the retina?” His is somewhat of an opposing view. He says, “Well, yes 51

in some ways it does. The shorter the wave length, the stronger the energy. You get beyond blue to ultraviolet. This damages the retina or any other tissue to a greater degree the shorter the wavelength becomes. So blue light can damage eyes but I don't think evolutionarily we have evolved to the point of seeing blue light and much damage is done to us. Our lens filters out much of the blue light and that's the reason we often develop cataracts as we grow older because the lens has been filtering out a lot of the bluer or shorter wavelengths. But, take out the lens for cataract extraction, it's possible blue light may give us further damage. It may also be possible throughout the years of aging that blue light does do some low level harm to the retina. But I can't believe there will be much harm from blue light evolutionarily. I just don't think we've evolved to be able to see blue light and have it damage us to a great extent. Besides, if it did, you wouldn't be able to enjoy the beautiful sky, a lot of the beautiful flowers around us. Blue light blocking for computers may have some role in a number of issues. It may have something to do with Circadian rhythm. It may have something to do with upsetting the normal visual mechanism. But again, I come back to the point that we have evolved to see the blue light and that was probably the oldest photoreceptor that is probably the first light that we're able to perceive, blue, blue green. Now, close work is a different matter. We've talked about the fact that maybe that stimulates myopia but it also stimulates some other things. It decreases your rate of blinking. It causes intense concentration on gaming or writing or whatever you are doing at close work. So there may be other factors there. But again, I don't think blue light is going to be so harmful to us. 52

IMAGE: ILENE MATTISON-SHUPNICK CHAPTER 5 There Are Too Many That Cannot See A good part of the SIGHT documentary project is a part of Brien Holden, OD PhD, Professor of Optometry, University of New South Wales, founder, Brien Holden Institute.How, why should we get involved? How did many of the ideas shown in SIGHT get started?“...In 1999, two of my friends, Nag Rao in India, Hugh Taylor in Melbourne published papers showing that the number one cause 53

of vision impairment in their societies and later throughout the world was uncorrected refractive error, which didn't mean a lot to me because as an optometrist, a person needs a pair of glasses you do an eye examination refraction, you supply them with glasses. My friend Nag Rao said, ‘Brien you've got to take an interest in the people in my country, 90 million of them who don't have a pair of glasses’. I said why Nag, anybody can get a pair of glasses. He said, ‘well that just goes to show you what living in the lap of luxury of Australia does for you. The fact of the matter is we don't have enough people to do the eye examinations, we don't have affordable spectacles, you should do something about it.” Lucky for us, Dr. Holden did just that and the discussion of eyecare and eyewear around the developing world has evolved continually with the help of the foundations, organizations and individuals dedicated to improving vision, at almost all costs.What happened by 2006?“I met a number of people that would continue to work together, Kovin Naidoo in Africa was pushing the frontiers of developing vision care in Africa. Optometry, Kovin, Nag Rao and Hugh Taylor and other people were interested in getting the job done... By 2006, the World Health Organization (WHO) had said the most important cause of vision impairment is uncorrected refractive error. It prevents children from learning, it prevents adults from working, and it prevents older people from enjoying the quality of their lives. This is an important priority was pushed successfully by Serge Resnikoff (WHO) and Christian Gunns (President, IAPB, Christofel Blinden Mission). Kevin Frick from Johns Hopkins and worked out and published the WHO bulletin... the cost of people not having glasses was 202 billion US dollars a year in lost productivity and indirect and direct expenses. But it wasn't just about the money it was about 135 million people who couldn't see at distance because they didn't have a pair of glasses and then we did research to find out that around the world more than 500 million people couldn't see up 54

close to work, do their domestic duties, make their crafts, or any of the things that you need to do up close when an older person, because they didn't have a pair of reading glasses. And people would say, well why do they need reading glasses? Many of them can't read. It wasn’t about reading, it was about all the things you do up close to advance your society and your economic situation. 90% of the people in many African countries did not have a pair of glasses for reading, which was absolutely shameful for our planet to not be able to supply somebody with a critically important piece of their lives, mainly their vision, either at distance or near. So by now we had understood that about 640 million people, around the world, were blind or vision impaired and that produced a worldwide response from WHO, from the International Agency for Prevention of Blindness, for Optometry, Optometry Giving Sight, support from Ophthalmology, setting up vision centers all around the world. So here we are with a world where 10% of the population can't get a pair of glasses because there aren't optometrists to examine their eyes, their aren't optical dispensaries to make the glasses and there aren't affordable spectacles. The solution is a massive worldwide program. Particularly related to developing human resources in every country and area in need because the only way to solve the problem is to train the people 55

who do the work in the societies to advantage the people.”2.5 BILLION PEOPLE IN THE WORLD WITH UNCORRECTED VISION 00:00 / 00:00 Jayanth Bhuvaraghan, Chief Corporate Mission Officer, Essilor, and Kevin Frick PhD, Health Economist, Johns Hopkins Carey Business School, dimensionalize the opportunity.Hon. Bob McMullan, President, International Agency for the Prevention of Blindness (IAPB)What is the structure, purpose and goals of IAPB? “IIAPB is a network of all the agencies, people have heard of in the various countries, that work on prevention of blindness. Voluntary agencies and professional bodies like the International 56

Counsel of Ophthalmology and of Optometry and the World Blind Union. It's a coordinating network. We mobilize community support and public opinion to help them and help all our members be more effective in restoring sight.”How bad is the vision crisis today?“It's frustrating that it continues to be so big because the world is full of crises but this is one that we can do something about. This is a problem we can solve and the problem of avoidable blindness is much too great in too many parts of the developing world. and we have emerging crisis’s with the global diabetic problem. There's diabetic retinopathy and macular degeneration as two emerging trends. The difficulties to get high enough up the priority list of most countries because many of these people are facing all sorts of challenges that seem to be and sometimes are more serious for the individual. Most of the issues we deal with have significant social economic cost for the individual but, they are not life threatening. It's a problem that could be solved cheaply and we can give them the mechanism to do it. They respond positively but it's still hard to get it high enough of the priority list to get enough resources.”What is the cascading effect when there is somebody who is blind in a developing world family?The best way to symbolize it is to think about a family in a village. If somebody can't see at all, has two cataracts, they are not socially contributing. Somebody has to stay home and take care of them. Usually it is a girl. Then, the girl doesn't get to go to school. And so her life is blighted by that absence of education. It cascades through her family because she hasn't had the education and you get a cascading effect from an avoidable issue that we could solve so easily. We have the skills, we have the knowledge, we have the resources, we just have to apply them and we can transform the lives of the person concerned 57

who can go back to being productive and we can liberate their family.”SOME LOSE SIGHT TO DISEASE Rebecca Alexander, Psychotherapist and fitness instructor. Describe your condition...“I have something called Usher Syndrome which means I'm progressively losing both my vision and my hearing.The vision part of my condition is called Retinitis Pigmentosa or RP, and it generally affects larger populations than Usher Syndrome. So if a normally sighted person can see a 180 degrees when looking straight ahead, I have about 10 to 12 degrees of my central most vision, and then a very small sliver of vision in my outer most periphery. My best vision is my central vision because we can't focus our periphery. I was diagnosed with RP when I was 12 and then further diagnosed with Usher Syndrome when I was 19.”How has this impacted your family and yourself when It comes to daily activities and what you get to do compared to someone who has, good vision or has the ability to correct their vision?“I think I try to live my life as normally as anybody else, and I'm constantly making adjustments based on my environment for my needs e.g., whether a place is too dark and I need more light. If I'm reading something and the print is too small and I need to make it bigger. I'm constantly adjusting myself to whatever the 58

circumstances that I'm dealing with. I think for that reason it's a very humbling condition to have because it constantly reminds you of how fortunate you are to have even the small bit of whatever it is that you are working with, however much sight it is that I have. And my family is wonderfully supportive. I don't live with them anymore and my progression really started to happen more after I left my parents house, and so a lot of this is kind of been post teenage 18 years old and so I've dealt primarily with most of the day to day issues on my own but they've always been very supportive of me in terms of you know, attending Foundation Fighting Blindness conferences and keeping up to speed on what research is out there.”Tell me about independence and you use a cane to get around.“I work until late, usually until sometimes 9:30 or 10 o'clock at night. I see patients and so often times when I'm at my office late people like to come and pick me up and I don't even necessarily ask them to do it. I mean I have my cane to use at night and I feel very independent with it. But I think that for other people, because I'm their loved one, I think that they feel very helpless in many ways to not be able to make my circumstances any different or any better, it allows them to feel as though they have a sense of purpose or that in some way they are contributing to my ability to be as independent as possible.” (Author’s note, click here for more information about Orientation and Mobility video at Vision Aware, AFB.)What is your plan after climbing Mt. Kilimanjaro?“I wrote my book Not Fade Away specifically because I wanted people to know who have Usher Syndrome or any form of debilitating or terminal illness, just to know that they’re not alone, that we all face something in our lives on a day to day basis, or at some point in our lives we're confronted with something that's very challenging. And so you know, I set goals for myself the same way I would if I was fully sighted and fully hearing and so 59

whatever my goals are I just always know that it's likely going to take more people to help me in the effort to accomplish my goals or I may need people to help me with it. But I can still accomplish whatever it is that I really decide I’d like to do. I think it's so important for people with visual impairments to come to a place of whether it's acceptance or the ability to just come to terms with what their circumstances are because the more comfortable we are being out in public and saying that we need help or using a cane, the more we become a part of mainstream society. And the more confident you are with whatever it is that you're dealing with the more other people will be comfortable with whatever it is you're dealing with. So if you see someone who's visually impaired and clearly is able to communicate their needs, it makes you a lot more comfortable being able to help them with whatever their needs are.” Are you scared about being completely blind?“Here I am, however many years later with a lot less vision and a lot less hearing and I'm doing just as much if not more then I've done in my life before. So I know that whenever the circumstances change and that I need to for instance, get a guide dog or use my cane during the day that it will be a difficult transition. I think sometimes people ask me how I maintain such an upbeat attitude and part of the way I do that is that I allow myself to mourn the loss. I allow myself to cry, to be sad, to be angry, to experience the emotions that come with it and that I continue to move forward. So it won't be easy but I definitely think that whatever happens it'll be okay.”...WAR 60

Edwin Silva, Marine Corps“I joined the Marines a year after graduating high school in August 2000. We deployed in August of 2001, and were overseas is when 911 happened. We happen to finish training with the Royal British Marines in Australia and we had our one night of liberty call in Darwin. Next thing you know everything just hit the fan. Police are running down the streets, Shore Patrol is running everywhere grabbing every sailor, marine, part of the ship just dragging us back to ship telling us, \"we gotta go, we gotta go. It's not a drill.\" It was just a massive muster. From then on, you know, the conflict began.”Edwin was in Pakistan and Afghanistan until a return to the US in April 2002 when deployed to Kuwait at the end of 2002 and participated March 20, 2003 in Iraq at the start of Desert Storm. Edwin returned home after multiple deployments (Okinawa, Japan, Fallujah), then a 5th deployment, again to Fallujah, Iraq. “We were supposed to do a over watch position and keep an eye on the road, make sure nobody set any more booby traps. There is something called moon dust which is as fine as baby powder. When you bury something it's damn near impossible to even see it, especially three or four in the morning when it's pitch black. We went to go check out a vehicle that was stuck in the road, cleared it, on the way back a daisy chain of IEDs went off... launched me in the air and...I got hit in the neck. My right bicep, it's..I'm missing 50% of it. I 61

ended up suffering a traumatic brain injury, frontal lobe damage, a little PTSD, and you realize that it's the TBI that's the worst one of them all, you're worst enemy, not the blindness. A TBI is a traumatic brain injury. It can be sustained by anyone who takes a blunt force trauma to the head. I went from Tikrit Iraq to Landstuhl Germany. I kept flat lining. I had three flat lines, 6 blood transfusions. I woke up from an induced 3 week coma in Bethesda, Maryland. They had to induce me because every time I kept waking up, I kept getting up an dripping tubes out of my body pretending I was in Iraq looking for my rifle. Just completely disoriented. The first question I asked was, \"why can't I see?\". I heard voices and they said, \"oh your eyes are stitched shut\". Later on the doctors told me there's nothing they could have done for my sight. I left Bethesda Maryland a few days before Halloween of 2007. By November 12th I was in the VA’s Western Blind Rehab Center, Palo Alto, CA and that's where my journey began with the blind rehab center.”Edwin’s treatment and rehab required almost a year to address his PTSD, getting weaned from the variety of drugs he took, he describes the turning point...“I was able to think. I was able to respond. I can give you an answer right away. I can problem solve a lot better. I wasn't as angry. I laughed a lot more and I smiled a lot more, and I was able to just truck along a lot better. Just accepted it. It could be worse, it could be worse and I just started to just live.”“Going out is interesting. You meet a lot of interesting people that try to help you out, and they don't know how. Sometimes some people want to help me cross the street, they grab my cane and just pull me. A lot of people, all over the US have good hearts, at the end when you get to the end of the street it's like, oh, that was dangerous but thank you. Traveling, it's fun. It's fun being blind. You just put people out of their comfort zone for a bit. But 62

traveling alone, it's very dangerous but it's very exciting. It's very rewarding. You do something for yourself and at the end of the day you get that sense of accomplishment, it's over, it's done with. When you do it when you're blind you just feel a little better.” (Author’s note: for more information, click here for AFB.org about being a sighted guide or Courtesy and Rules of Blindness, National Federation for the Blind)And you live on your own?“No. I live with my wife and kids. I'm one of the few lucky ones who was able to keep my wife and kids and everything through PTSD battles, from traumatic brain injuries and just the whole, the whole cluster of being blind, especially with all the other stuff that's wrong with me. I volunteer twice a week, it's non paid work at the San Diego Center for the Blind in Vista. I teach the iPhones, iPads, how to type. how to deal with rehab, a grocery bag or just what happens when losing sight, oh man, what do I do now? A lot of people can't afford rehab training so I volunteer, help them out, just you know, help them see a little bit of the world even if their little computer, iPad, iPod, phone, anything you want to call it, just try to reconnect them to the world and it's very rewarding. There's an application called Blind Square. It's an application just for blind people, a GPS. It tells you what's around you at all times, where to go, how to get there. It's interesting. It's really cool. My day is interesting. I wake up three or four days a week at 5 am. I get ready. Six o'clock I take the bus from Oceanside to San Marcos and I train at San Diego Brazilian Judo and Jujitsu down in San Diego. I do Brazilian Jujitsu for few hours a day just to get the aggression and just live in the moment. It's nice, you and the mat. No phone, no electronics and it's just, it's a little deja vu of being just an active duty member again. Class starts at 7 and ends around 8:30 but I stay in the back the 63

Dojo. I listen to my audiobooks, catch up on news and then I work out for a little bit and then roll from 11 to 12:30 class. From there I go home and I just see what my wife needs me to do. A lot of the people that do Jujitsu are college students, and I get to pick their brains and it's helped me build that courage to go back to school and finish what I've dropped out of. I never looked forward to something like that as much as I have nowadays, just think about it. Just engage, to learn, to, I think I'm ready now.”.. TOMMY EDISON, HOW TO OFFER HELP TO A BLIND PERSON 00:00 / 00:00 Edwin Silva described how ‘...Sometimes some people want to help me cross the street, they grab my cane and just pull me.” There’s a better way, watch this video by Tommy Edison for better ways to assist the blind (from You Tube https://www.youtube.com/watch?v=X44eLRvQzVw)...ACCIDENTS 64

Christopher Dean Raider, Marine Corps“When I was in the Marine Corp I was in 0811 which is field artillery. I was the lead gunner of, gun 4 for alpha battery first battalion 10th marines. I was in Iraq from March till I believe July, 2003, 3 months. I had PTSD when I came back but it was something that I didn't want to admit that I had so I never asked for help on anything. I tried to sign up for the VA when I first got out but I would go to like different veterans associations and they told me, no you got to go here, you got to go here, and I was in a place in Vegas I just didn't want to go. So I never signed up and I just took care of my own self-medication.”Can you talk about that accident? “It was June 7th of 2009, I did a poker run on my motorcycle... I'm going to race home and catch a power nap and on my race home I did not make it, I woke up three months later in a hospital. I read the police report... the vehicle in front of me was going 15 miles an hour, right after an intersection and because I was racing home I was going approximately 70-80 miles an hour when I hit him and I went flying past another motorcyclist, who I almost hit head on. And after 50 feet, that's where I ended up, me and the motorcycle caught fire. From the accident I got a traumatic brain injury or TBI. The doctors told my parents I will never walk and talk again. I don’t give up. 65

I have a brain injury with vision loss from the optic nerve. My right optic nerve is gone so I have hemianopsia, the whole left (visual) field is gone. Before the accident, did you think that vision was in the brain? I have learned a lot about vision and vision disorders and it's one thing that I do is, I help any blind person I see. From the accident I sustained what called left drop foot which means the foot doesn't work, the brain just doesn't realize I have a foot so I have to wear a prosthetic device that shocks my leg with a weight sensor at the gate of the ankle to lift my foot every step. From the traumatic brain injury it is hard to remember, every day is a challenge because I don't remember half the time what I did the day before.The optic nerve was damaged in the accident, describe your field of vision. My field of vision, no matter what I look at, picture a stop sign and draw a line down the middle of it and all I see is the OP. I have a different type of prism glasses because I have double vision almost 24/7. I'm going to the blind center to work on that. I close my left eye automatically to get rid of the double vision and with that they are afraid that the left eye could actually shut off. The optic nerve actually treats both eyes so both of my eyes have the field loss in them... just have the right hemisphereBefore the vision loss it wasn't even something that I thought about was vision. I have never had to wear glasses. Since the vision loss I have had Lasik eye surgery to where I don't have to wear glasses and I got 20/15 vision in the right hemisphere. I have great vision but the field loss catches me every once in a while. If I'm not paying attention I'll walk into stuff and I use a blind cane which tells people I'm visually impaired. There's the white and red cane and then there’s the yellow cane. Why two different canes? 66

There are two different canes because I am not legally blind. I need to lose ten more degrees of vision and then I will be legally blind so I use a yellow cane which I have to explain nonstop what it is for. You said it's kind of an insult because you're vision loss is just as if you were blind? Correct? Yes. To be truthful, I could care less what color the cane is but it is part of something that people have to stop and ask what is that for when the law from the 50’s says that if you're not legally blind you can't have a (white) cane. (Author’s note, for more information regarding the White Cane Law in your state, click here.)The VA introduced me to voice over on an iPad, touch the screen and it tells you which app you're trying to open and you would double tap and it opens the app and reads your messages. Because of that and college I want to know ever operating system so I've gotten an Android and a Windows tablet. They all have blind accessibility that I am learning.”If you have 20/15 vision, why do you need the aids if you actually have decent vision in half of your sphere? “I use the aids because the left field is gone and for reading you have to scan back to the left after you finish a sentence and I ended up reading the same sentence three or four times if I'm not keeping my finger along the page. These accessibilities make it much better to learn after a traumatic brain injury because you get the audio, the visual, and that actually helps more for memory. I used to be able to run, which I can still run but it scares me with the drop foot and I use to be able to do a lot of other stuff. Now, you know, I use a cane and I still walk into things if I'm not paying attention and day to day life I work on school work and I'm not going to lie, I play games on my iPad and I take the bus which is a 67

direct route to the college. I can do the movie theatre but I have to use the peripheral vision on the right to even see a full movie and that's one thing I argued that I wasn't blind because I don't remember what full vision is like from the brain injury. They took me to a movie for recreation therapy and that's when I realized I was blind, I couldn't see half the screen.”Let's talk about the blind center. What are the people like there? “The people at the blind center are some of the smartest people I know. I can call them for any problem I am having. I was reading and if I tried to focus on anything I close my left eye. So I contacted the blind center. We are going to do some more mobility which is hard with my memory, have me find a different target which if it's a regular hallway they'll stick sticky notes on each side and count how many of the sticky notes you can find by scanning. At first I didn't admit I was blind, I would argue that you know it was pointless to do the exercises until that movie theatre a year later. I walked into a pole and broke my nose and I was like, I need more training. And that's why it lead me to use the cane even though nobody knows what it's for. I've been through a lot of relationships that have accepted me for my disabilities and some that just haven't. I have learned, you might not want to talk to somebody but you know what... you talk to them and you get to know them, they are actually really good people. Like one of my neighbors. We never talked and then I forget what brought us together and we are great friends now. I gave him a chance and you know what, he ended up being a good person.”...GOOD PEOPLE 68

Gregory Goodrich PhD., recently retired, research supervisor, research psychologist, Veterans Affairs, Western Blind Rehabilitation Center, Palo Alto, CA.“The eye is very important for vision. It's kind of the entry point but what we think of is vision is really the world around us and all the information taken in through the eye is processed in the brain and that's where we form our perceptions, where we integrate our vision with our appropriate senses, standing up being balanced, and integrated with hearing and all of our other senses. There are actually interconnections in the brain between all the senses. Over 50% of the brain is devoted to vision in one form or another. So any injury to the brain can lead to a variety of visual disruptions. Some are transient. Some people when they have a concussion will see double. But that will resolve quickly. Others become more permanent conditions. They can range from binocular disorders where the two eyes don't function together, up to total blindness. There are also including things like hemianopsia and quadanopias which are technical terms. Hemianopsia is you've lost half of your field of vision. A quadanopias is you've lost a quarter of it and that's making things quite geometric which may or may not be true. It varies greatly between people. Injuries can happen to the pathway between the eye and the brain or it can happen in those areas of the brain that process vision, where the nerve fibers in the brain are actually damaged, 69

becoming nonfunctioning. In most cases that's a permanent loss but not always. The brain has a good ability, what we call plasticity, it can reroute around damaged areas sometimes, and sometimes there maybe some regrowth of new neurons. Traumatic brain injuries made me realize that all vision and rehabilitation is leveraging brain plasticity. If you have age related macular degeneration you need to learn new ways of reading or doing other near tasks and that involves rewiring the brain on how it sees. You are using not your central vision, which was lost, but more a peripheral area. You're able to learn to use that to its best capacity.” What are some of the best example of retraining the brain? “Some of our troops coming back with hemianopsia... There is a condition called neglect. You've lost half of the vision in the left eye, corresponding half of the right eye. In neglect, not only have you lost the vision you don't know there is anything there. It's a very interesting condition from a research point of view. Very frustrating to rehabilitate because the person may deny that they even have the condition. They retain 20/20 visual acuity. So what could be wrong with the visual system? One of our successes was working with an Iraq veteran who came back with neglect and hemianopsia, didn't know why he was being referred here because there was nothing wrong with his vision. Although, he had a tendency to walk into the left side of doorways, or trip over things that were on his left side. He, walking into a doorway, he'd ask who designed this door. It's wrong and not able to grasp that he had a vision loss at all. So we did a video imaging of him where we actually tracked his eyes as he was moving down a corridor and then we replayed that for him. He was able to see that he wasn't turning his head to the left, he was coming close to things on his left side that he didn't realize and so he began to accept that he had a vision loss. Working with him, he was able to learn to scan to the left, bring 70

his good area of vision into play, and you know, walking through doors was no longer a problem. He wasn't tripping over things. So he was functioning much better than he was before. So in large part it's just getting people to understand what their vision loss is, what is causing it, what it does and that realization then is your first step in rehabilitation.” Step back a little bit and talk about the soldiers that are returning with their injuries. “IEDs still cause shrapnel injuries, pick up and throw everything that's in their path. One of the things of course that has made a major different is that someone from my era, the Vietnam wars would not have survived the kinds of blasts that our troops are now surviving. Battlefield medicine is dramatically better then what it was. So, we see people coming in with vision loss that we haven't seen before and understanding that has become critical. I think we've done a pretty good job of that but there will be more intricacies in the rehabilitation process. You'll have a person who has a vision loss, from a TBI but may also have a cognitive loss, cognitive impairment, memory loss, attention loss, and you may even throw into that mix things like PTSD. So how the person responds to all of this is of interest. Also of interest is how we go about providing rehabilitation in some kind of reasonable sequence and reasonable time frame. Generally in rehabilitation everybody wants the patient as soon as possible. But you know, you first address the medical issues, then you can address some of the self-care issues, and then you can start bringing in vision, speech therapy if it's needed and all the other types of rehabilitation that are necessary. Sometimes that can be done in a fairly short term time frame. Other times it can take years. We've been working with some veterans here over a period of three years, in their rehabilitation. You work up to a point where they have gained as much as they can at that time and they plateau. You can send them home and 71

they can enjoy family life and practice what they have learned and they come back in and you go to another level of rehabilitation and then go home and come back. And that's a fairly new model for vision rehabilitation. The VA, it's kind of a serial model. But it seems to work most effectively for some of our TBI veterans with vision issues.” Historically, have vision problems changed by each war?“We can actually go back to the Civil War. Blindness and vision loss was not the most common of injuries. It was about 2 to 3 percent and up through World War II, and Korea the number of vision injuries did increase but they were due to bullet injuries and shrapnel injuries. Blindness was a fairly common outcome. Starting with the Gulf War though, we started to see a great uptick in eye and vision injuries. Probably 12-15% of all injuries are related to the eye or the visual system including the brain. And so vision injuries from war have dramatically increased in large part has to do with the change in the nature of weapons. In the Civil War you had single fire rifles and relatively primitive artillery. In the wars in Iraq and Afghanistan you had very sophisticated and very powerful IEDs that created a blast wave that was sometimes seen in major battles in prior wars but people didn't survive those. Now they are surviving them and so we are seeing a whole variety of new injuries. Historically we have seen vets, between the ages of 65 and mid-90s. They have conditions like age related macular degeneration, diabetic retinopathy, glaucoma, and some others but those are the primary ones that we see. Starting with the wars in Afghanistan and Iraq, into that mix we started seeing younger guys come in and men and women both with blast related injuries and that was creating an interesting dynamic because you had people 19, 20, 21, 22, coming in to a facility that had basically been set up to serve an older population and the type of injuries were dramatically different. 72

The rehabilitation issues were also more complex because of the other coexisting conditions within the TBI, the memory cognitive issues and so on. And so that was a very interesting transition that created some friction initially but in the end enhanced the whole program in large part because we started realizing that vision really isn't just about the eyes, it's about how the brain processes that information. So the silver lining in all of this I think is that it's really improved rehabilitation services for everyone.”RESOURCES Foundation Fighting Blindness Vision Aware, Orientation and Mobility Blind Rehabilitation Services (BRS) The Blind Rehabilitation Programs:• Support blind and low vision Veterans and active duty Service members in regaining their independence and quality of life to enable their successful integration into family and community life.Support family and significant others to better understand visual impairment and foster the provision of appropriate support, to assist in enhancing home environments and to reduce caregiver burden. 73

American Foundation for the Blind, Being a Sighted Guide The Courtesy Rules of Blindness American Council for the Blind, White Cane Laws for StatesAuthor’s note, for more information on community based services for non-veterans click here for information and resources from the American Foundation for the Blind and Vision Aware. For more information on resources for blind veterans, visit Blind Veterans Association or Vision Aware for information for veterans coping with vision loss. 74

CHAPTER 6 Eye Conditions Myopia, Hyperopia, Astigmatism, Presbyopia Good vision is the ability to see clearly, often defined by ‘20/20’. However, there is more to good vision than 20/20. The American Optometric Association describes it this way, “20/20 vision is a term used to express normal visual acuity (the clarity or sharpness of vision) measured at a distance of 20 feet. If you have 20/20 vision, you can see clearly at 20 feet what should normally be seen at that distance. If you have 20/100 vision, it means that you must be as close as 20 feet to see what a person with normal vision can see at 100 feet.​Having 20/20 vision does not necessarily mean you have perfect 75

vision. 20/20 vision only indicates the sharpness or clarity of vision at a distance. Other important vision skills, including peripheral awareness or side vision, eye coordination, depth perception, focusing ability and color vision, contribute to your overall visual ability” (http://www.aoa.org/patients-and-public?sso=y) We’ll see how eyeglasses and contact lenses, your eyecare professional (Optician, Optometrist and Ophthalmologist) and regular care of your eyes contributes to perfect vision. Some of us though, have lost the capability of perfect vision. There is exciting research and invention to help, as well as the support systems provided by rehabilitation counselors, State and Federal programs and the various foundations working for the visually impaired and blind. We will weave these options as we discuss eye conditions and common diseases. EMMETROPIA We start with EMMETROPIA, that’s normal visual acuity or “20/20” when tested. 20/20 means that the 20/20 line on an eye chart can be read correctly from a distance of 20 feet away. If a patient can read the 20/20 line we say they are emmetropic. 76

Look at the eye. We have added a bundle of light rays hitting the cornea. They get bent (refracted) until they come to a focus on the retina at the fovea (the arrow).The emmetrope can buy any pair of ready-made sunglasses and does not need a prescription for eyewear. However, someone you see that does not wear glasses or is wearing plano (non-prescription) sunglasses could be a contact lens wearer or might never have had their eyes examined. Remember, not everyone that needs an eye exam has had one. Someone that needs glasses might not have them.MYOPIALook at the eye’s cross-section below. Light comes to focus in front of the fovea. We can say that the eye is too strong. We call this condition MYOPIA or near sightedness. Things up close are clear like the boy and the flowers in the foreground but objects far away, behind him are blurred. 77

If the correct diverging or minus lens (a lens that is thinner at the center and thicker at the edge) is placed in front of the eye, the rays focus on the retina. Now the flowers in the background are also clear. See the image below. When someone is myopic, his or her prescription would have minus (-) numbers in the first column on the Rx form, labeled Spherical or sometimes SPH. If you held up their glasses at arm’s length and looked through them, the world would be minified. 78

This prescription has a place for D.V., Distance Vision, N.V., Near Vision and the O.D. (right eye) as well as O.D. (left eye).HYPEROPIA The opposite is called HYPEROPIA. It’s when the eye is not strong enough to focus light onto the retina. A hyperope sees the word far away clearly rather than up close, therefore this condition is called farsightedness. The flowers in the background are clear, the foreground is blurred.Now add a plus or converging lens just enough so that the focal point moves onto the retina at the fovea and vision is. 79

When someone is hyperopic, his or her prescription would have plus (+) numbers in the first column on the Rx form, labeled Spherical or SPH. If you held up their glasses at arm’s length and looked through them, the world would be magnified. MYOPIA AND HYPEROPIA 00:00 / 00:00 In myopia, the eye is too strong and elongated, hyperopia, too weak and shortened, both corrected by spectacle or contact lenses. ASTIGMATISM 80

ASTIGMATISM is a little bit more complex to understand. If the eye were too strong vertically than it was horizontally, then there would be two different focal points of the light entering the eye. This eye would be astigmatic. An astigmatic eye that requires two different corrections creates a blurred image that is also distorted differently vertically and horizontally. That’s because most corneas are more football shaped than basketball shaped. Almost 3/4 ‘s of prescriptions correct for astigmatism. Eyeglass prescriptions can be myopic, emmetropic or hyperopic and astigmatic. Correct both directions with a lens that has two different powers, here different vertical from horizontal and with just the right 81

amount of power and both focal points fall at the same place on the retina at the fovea. Prescriptions for astigmatism have values in the Cylinder (sometimes CYL) column and also an orientation or angle called AXIS.Look at the left eye’s prescription (OS). This patient is hyperopic, a plus power needed in the spherical column, and a cylindrical power specified along with an axis (rotation angle of the football). This patient is astigmatic in the left eye. However, they are only hyperopic in the right eye (OD), there is no astigmatism. ACCOMMODATION 82

Your eye is amazing because the lens inside the eye changes shape when you have to focus from far to near. It gets thicker and more convex. Look at the top illustration of the eye, Look at the top photo, the far away mountains are clear but the New York Times Magazine is blurred. If you now focus on the magazine, it comes into focus and the mountains become blurred. When we look at something up close like reading a book, we moved an object closer and the focal point moves behind the retina. To move it to back onto the retina we need a plus lens. Now this is not hyperopia where the eye is too short or not strong enough. This is called ACCOMMODATION and it means that the lens in the eye can change shape to focus from far to near and everywhere in between. Accommodation, make the lens more convex, i.e., more plus and focuses the object on the retina. In the bottom illustration, the lens is exaggerated in shape, it is more convex.PRESBYOPIAIn an eye condition called PRESBYOPIA, the lens inside the eye cannot accommodate i.e., change shape to increase plus power and see up close. You know someone that is presbyopic or perhaps you yourself are... It’s normal after the age of about 45.The reason is that the lens adds layers (like an onion), your entire life. This compresses the inner most layers. The result is that the lens becomes more and more rigid, loses its flexibility and is unable to become more convex. Starting at about age 7, your ability to focus at 5 inches begins to move away from you. By our early 40’s the book or tablet is almost at our fingertips with an outstretched arm. 83

Look at the man in the picture – this is a common initial solution for early presbyopia. Can’t see up close, move the reading material farther away until clear. What happens when your arms are no longer long enough?A simple pair of reading glasses can help, solve a major problem, for many populations, especially outside the US. Foundations like OneSight (OneSight.org)and RestoringVision (RestoringVision.org) with the missions they supply, can help deliver reading glasses to those in need.Plus lenses come in a variety of forms like ready-made readers that many people use. These help but are rarely the correct power as it is likely that each of your eyes, once presbyopic requires a different lens power. Eventually, consumers get a much needed eye exam and the right lenses are purchased. Prescription reading glasses may be single vision or provide multiple areas of clear reading glasses and usually come in the form of progressive lenses (where the clear vision for far, mid-range and near vision is all in focus), some people prefer bifocals (a lens with far and reading vision only), or have either a pair of reading glasses or more effective, computer/office type lenses that deliver reading plus clear vision to about 5 ft away. They are not intended for far vision so one would not use them for driving. There are many wonderful choices whose benefits an optician or optometric assistant can make very understandable. 84

Contact lenses are also an effective option once presbyopic. Many previous contact lens users wear mono-vision contact lenses i.e., one eye wears a contact lens for distance vision, the other wears a contact for near. Your brain does an effective job sorting out which of the clear images is used so there’s no confusion. Talk to your Optometrist or contact lens specialist about whether Mono-vision contacts will work for you.The prescription for a person with presbyopia has numbers in the Add or Near Vision boxes. This means that in addition to the far vision prescription required, additional plus power is needed for close work. How close? Your doctor will help assess your most common reading requirements and tune the ‘Add’ to the right numbers.In this instance, Mrs. Diaz has a +2.00 Add so she requires a plus 2, sphere lens in addition to her distance prescription. She’s nearsighted and astigmatic for distance vision. Again, an optician would discuss the choices that best meet Mrs. Diaz’ needs so that she benefits the most from the lenses and frames chosen. 85

Children's VisionCHILDREN’S EYE EXAMSCHILDREN NEED EVERY OPPORTUNITY TO SUCCEED IN SCHOOL... 00:00 / 00:00 “Children don’t usually know they are not seeing well...” 86

Howard Purcell OD, Sr. Vice President, Customer Development Group, EssilorCHILDREN AND EYEWEARFrom the 2012 US Census, there are about 60 million children in the US today, 14 years and younger. That’s about 20 million each for the age groups, less than 5 years of age, from 5 to 9 and 10 to 14 years of age. There are about 5.6 million in Canada. The question is, “Do children get their fair share of vision care and are they at any special risk as children without it?” From a 2009 Vision Council report, called “Making the Grade’, it is estimated that 1 in 4 children have a vision problem that interferes with their ability to learn. According to the National Eye Institute’s Vision in Preschoolers study, there are several vision problems that are commonly found among school-age children. They are amblyopia, or lazy eye, which affects two to five percent of preschoolers and strabismus, in which eyes cross in or turn out, affect three to four percent. The study also found that 15-20 percent of preschoolers had significant refractive errors. If we add that together we get 20 to 29% having vision problems or about 1 in 4. The question therefore is, “how many kids that need glasses don’t have them?”POOR VISION AND LEARNINGFrom SUNY College of Optometry, nationally it is estimated that 87

only 7% of kids have had a comprehensive eye exam by the start of first grade. Even more concerning was that only about half hadhad an exam by high school graduation. And, if 80% of what children learn in their first 12 years comes through visual processing of information. There’s a problem that has a solution.There are many sources; the AOA, AAO, National Institutes of Health, other, that have described how untreated impaired vision can affect the learning or cognitive, neurological and physical development of kids. Can’t see well? How does it affect learning to read, riding a bike, running and ultimately self-esteem?SCHOOL SCREENINGS Not all kids get screened for vision issues before starting school. From Making the Grade (The Vision Council, 2009), there is great variability across the US, state by state, in what is required for children when entering school. From the report, “As many as 80 percent of children who fail a vision screening do not receive a follow-up eye exam by an eye doctor as recommended.” The statement says it all. Image: Ilene Mattison-Shupnick CHILDREN AND SUNWEAR 88

Let me give you an important fact about kid’s eyes and their development by illustrating it with a question. What percentage of UV RADIATION is transmitted through the crystalline lens of kids 10 years and younger? Is it 75%, 60%, 35% or 10%? The answer is 75%. It turns out that the lens in kid’s eyes at about 4 years is transparent to UV i.e., UVA goes right through to the retina. By age 10, a protective chemistry is developing in the lens to absorb UV. By age 25, only about 10% gets to the retina. So, the body is designed to protect the retina from damage from UV radiation. UVA causes the lens to also change by turning it yellow (a by-product of UVA absorption) or results in a cortical cataract (UVB). Because of the lens’ initial transparency to UV, it is estimated that as much as 80% of the damage to the retina is done by age 21. Therefore, good quality, 100% UV absorbing sunwear is essential for kids early on and over a lifetime. Do you lather up your kids at the beach with sunscreen, for play outdoors? From a VSP newsletter, 82% of parents require sunscreen today but that’s not the case for sunwear. Only 32% of parents surveyed ensure that their child is wearing sunglasses when he/she is wearing sunscreen. Why is quality sunwear important for kids? Kids get 3X the annual exposure. They spend more time outdoors and small amounts of UV are accumulated over a lifetime. Blue eyes are at more risk for UV damage than brown eyes. From an Essilor newsletter article, “Eye color is created by melanin, which also dictates skin color. The more melanin in your iris, the colored area surrounding the pupil, the darker your eye color will be. Caucasian babies are born with no melanin, and thus have blue eyes, until about three years of age when their eyes darken to its permanent color Asian and African-American babies are typically born with dark brown eyes. More melanin means better protection from the sun-- the pigment in your eyes literally protects your retina. Light eyes such as blue, green or grey are 89

more sensitive in sunlight. UV exposure over a lifetime can result in cataracts, pingueculae, pterygia, cancers and AMD. A 20-year delay would practically eliminate these diseases as significant causes of visual impairment in the United States.” Therefore, it’s simple; sunwear for all children is required.CHILDREN’S EYE EXAMS, WHEN? Karla Zadnik, OD, PhD, Dean of Optometry, The Ohio State University, College of Optometry. When should a child be seen by an optometrist? How soon in their development? “It may seem strange but there is significant debate about when to see children for eye examinations. You could argue that before six months - that will rule out any grossly obvious problems like an eye turn or a cataract or even in some extreme cases a tumor inside the eye. Then a time between the ages of 2 and 3 and then again before starting school. Other schools of thought are that a child should be examine annually but I think that before six months, say two or three, and then again before starting elementary school is a wise path.”If parents are dealing with some behavioral issues in the classroom, should they include an eye examine as part of the assessment? “I think an eye examination should be included anytime a child is 90

struggling in school, or has received a special education plan of some kind. We know that the proportion of children with difficulties in school who have undetected eye problems is much higher than among children in general. Ruling out an eye problem makes sense. If a child is having difficult focusing to read for example, and they are in remedial reading classes, wouldn't you like to make it so they could focus on the book to at least get started.”What are the top three things that teachers should be looking for?“I think the easiest things for teachers to look for are things that a child avoids. Sometimes we might think, \"oh that kids just not much of a reader\". For example if that child gets a headache every time he looks at something up close he's probably not likely to be a reader. I would say children who exhibit avoidance behavior, who rub eyes a lot, eyes water, experience some overt symptoms of eye strain...squinting to see the board or seeming to not participate as much in class. Maybe if their in the back of the room as opposed to the front of the room and they can't see. Occasionally a teacher would be to see a really obvious eye turn where one eye is turned outward or inward in a way that would be cosmetically evident. A FIRST PAIR OF GLASSES 91

00:00 / 00:00 “What’s better...?” narrated by Sir Elton John Maureen Cavanaugh, President, Vision Impact Institute, “There are 37 percent of the elderly that have uncorrected vision... 30 percent of children today have uncorrected refractive vision, the statistics are really astounding.” RESOURCES Howard and the Amazing Eye Exam, a downloadable eBook from Alcon 92

Get your child ready for their first eye exam with this charming story about Howard the Hedgehog. Howard is Star Student this week and is excited to tell his classmates all about his first trip to the eye doctor. From a fun puppet show to cool 3-D glasses, Howard shows the class that visiting the eye doctor isn’t scary at all. It’s a lot of fun! The Vision CouncilYour child’s healthy vision does not just affect his or her quality of life but it is also vitally important in his or her development, from the time he or she is an infant through the school-age years. The right time to teach your child how to establish healthy eye care habits that last a lifetime is now. Even more important than helping him or her learn about caring for the eyes is recognizing and correcting any vision problems that may be starting or that have gone undiagnosed. AllAboutVision.com, Children’s Vision: What Parents Need to Know 93

CHAPTER 7 Managing MyopiaMyopia affects nearly a third of Americans. Worldwide, a number of countries in Asia have a myopia epidemic. In April 2015, CNN Vital+Signs reported, “The rates of myopia have doubled, even tripled, in most of East Asia over the last 40 years, researchers say. Several places like Hong Kong, Singapore and Taiwan have rates in the 80%. In South Korea, myopia rates among 20-year-olds have leaped from 18% in 1955 to over 96% myopia in 2011. And it's a global issue -- rates of myopia are also rising in Western nations like Germany and the United States. \"It's about 40% in the U.S., compared to about 25% in the 1970s,\" said Dr. Michael Chiang, clinical spokesperson for the American Academy of Ophthalmology.Investigation of the causes of myopia and treatments to reduce its effects or retard its progression are active worldwide. They include use of drugs, eyeglasses, contact lenses and sunlight. SUNLIGHT 94

Donald Mutti OD, the EF Wildermuth Professor in Optometry and Vision Science, The Ohio State University College of Optometry, Myopia Research “What's very alarming is that the numbers of children with very highly myopia, wear very thick glasses and have very poor uncorrected distance vision. Those percentages are really increasing dramatically... There are very serious consequences to the health of the eye when the eye becomes very nearsighted. It's very long and there are possibilities of retinal damage, of glaucoma, of cataracts, so eye disease, as well as the inconvenience of being nearsighted come with high levels of myopia.Causes of myopia are probably both genetic and environmental. Our research over the years and that of many groups around the world have found a very strong genetic component. It's very clear that near sighted parents tend to have near sighted children. But, this increase in prevalence in the last few decade, points to a strong environmental component. What we found was that the amount of time that kids spent reading, doing homework, watching TV, using a computer, didn't affect their chances of becoming near sighted at all but what was influential was how much time they spent outdoors. And what we found was that kids who spent more time outdoors would have a lower chance of becoming near sighted. Being outside was a good thing. And what we found in our analysis is that the near work was not related to becoming near sighted but time outdoors was it's own 95

independent separate protected factor reducing the chances the kids would become near sighted. We didn't see any relationship between the amount of near work a kid would do and the amount of time outdoors that a kid would spend.”“There are a couple of interesting things about this affect of time outdoors. One is that it only seems to be a benefit before the onset of myopia. A lot of parents with near sighted children say or ask me, are you telling me to send my kids outside, they need to be outside more? If your child is already near sighted it's an interesting finding that once near sighted this time outdoors doesn't seem to influence the rate of progression. So time outdoors isn't a treatment. It's important to remember, if your child isn't near sighted and you want them to spend more time outdoors, well, there's a lot of good things that come from that. If time outdoors is going to have any affect it has to happen in early childhood before a child becomes near sighted for the first time.”“Let's not forget that time outdoors has a lot of ultraviolet exposure and it's important to use the usual protections of sunscreen and sunglasses so that ultraviolet doesn't damage skin or eyes.” CAN SPECTACLES OR CONTACT LENSES SLOW THE PROGRESSION OF MYOPIA 96

00:00 / 00:00 Brien Holden PhD, DSc, OAM, from SIGHT, The Story of Vision CONTACT LENSES Dr. Mutti continues, “Every parent of a near sighted child watches from the time their son or daughter gets their first pair of glasses, their going to get stronger pairs of glasses through the teenage years and maybe even into their twenties. Recent studies have found that maybe there's a new idea and the new idea is to maybe influence the optics of the eye. Change the optics of the eye a little bit, particularly in the periphery of the retina. Not in your central vision, but out in your peripheral visual field so that you can see distance clearly, so you can see near clearly to read and do your close work but that the retina is seeing something peripherally that's different. Preliminary studies indicate that this may have some benefit and there's enough preliminary work that we were funded by the National Eye Institute to do a study to see if multi focal soft contact lenses could slow down the rate of progression in myopia. The study is called BLINK, Bifocal Lenses In Nearsighted Kids. You 97

think of bifocals as something that an older person might wear. These are standard food and drug administration approved soft contact lenses that somebody over 45 might wear to help them with their close vision when they have lost that ability to focus up close. But kids can wear these to see clearly at distance, use their own focusing power to see clearly at near. But what these lenses deliver is a different kind of optical profile to the peripheral retina influencing your side vision, changing the optics for side vision, or peripheral vision and what the preliminary data show, what experimentation in the laboratory has shown is that this kind of optical signal tells the retina to release a chemical cascade that ends up slowing down the growth of the eye and if the eye doesn't become large it does not become as near sighted.”MYOPIC MACULAR DEGENERATION Monica Jong OD, PhD, Research and Business Development, Brien Holden Institute, High Myopia Study. “We're interested in myopia, because this is a very deceptively simple condition which everybody believes that a pair of glasses can solve because they think that myopia causes blurry distance vision. In reality, how many of those people realize that myopia can actually lead to blindness? Myopia can cause blindness because of myopic macular degeneration. Myopic macular degeneration, retinal detachment, cataracts, glaucoma are also other diseases that you can be at a higher risk of getting if you have myopia. 80% of people are affected in East Asian nations by myopia. In the US, myopia has grown from 26 to 46% in only 3 98

decades.When people become more short (near)-sighted or myopic, the eye ball is actually growing longer. The back of the eye-ball has a thin layer of film... like a film in the camera. That film is also becoming stretched as the eyeball gets longer. As it becomes stretched, it's getting damaged, and when it becomes damaged, the area of the eye called the macula where there’s a higher density of rods and cones, which are the special nerves that we use to see light, those also are getting damaged in the process because of the stretching. The prevalence of myopia and high myopia and myopic macular degeneration is higher in Eastern Asian populations... we need to look at the reasons why it's higher.With the information that we will obtain from this study, it will help us to lobby governments, the World Health Organization and the National Eye Institute in bringing this public health issue to the forefront. At the same time, by understanding the disease more, we can definitely intervene with possible treatments to help prevent people from going blind.” Brien Holden, OD, PhD, Professor of Optometry, University of New South Wales“We started to realize that high myopes had a significant problem with permanent blindness. Studies started to come through in 2002 to 2008 showing that myopia, high myopia, where the stretching damaged the retina can be a serious impediment to vision. In Japan the number one cause of blindness is myopic 99

macular degeneration. It's not cataracts. It's not age related macular degeneration. It's myopic macular degeneration. And not only that, high myopia increases the prevalence and the risk of cataract and glaucoma so these concomitant diseases along with the fundamental of myopia on the retina is creating a class of blindness that had previously been unrecognized and still today is not properly captured in the statistics related to blindness.”LENS DESIGN“Earl Smith III OD PhD (University of Houston) does fundamental research to show that you can slow the progress of myopia by manipulating the shape of the image that falls on the retina or it's position. To explain that simply, if you take a babies eye, or a baby monkeys eye and you put up a negative lens in front of the eye and it pushes the image behind the retina, the retina will keep growing until it adopts the length where it gets a clear image. And that's called myopia increase associated with creating artificial hyperopia, or negative image behind the retina. If you put a positive lens up and bring the image in front of the retina then the eye growth will slow. What Earl Smith showed was that he and we and the field in general had been focusing on what happens to the central retina, what happens to the central vision. Nobody... had taken any interest in what happens in the peripheral retina. Dr. Smith did a series of experiments where if you put that negative lens in front of the eye but you cut out a hole so that the vision through the hole is very clear. He still found that the eye elongated because (light from) the negative periphery of the lens, falling on the periphery of the retina was enough for those retinal cells to send a message to the white of the eye, the sclera to grow. The peripheral image was driving myopia. While being published it is yet to get wide spread acceptance. We know that the peripheral retina is very important to the development of the eye. 100