Women & eye health at midlife.

Vicki Slone can cry now when she dices onions. When she rented the movie "Steel Magnolias" this summer, tears streamed down her face during the emotional ending. Maybe to you these events are no big deal, but to Ms. Slone, 53, who has lived with extremely dry eyes for more than 15 years, they are miraculous.

Ms. Slone is one of 3.2 million American women--nearly one in 12--over the age of 50 with dry eye disease, a seemingly benign eye condition that is anything but. More serious forms of the disease, like the form Ms. Slone has, can damage the surface of the eye and cause severe discomfort if not treated properly. In rare cases, dry eye disease may even impair vision.

But Ms. Slone was lucky. She joined a clinical trial for a medication that has since become the first prescription therapy approved for dry eye disease. She can now cry on demand, fly in an airplane without having her painful eye irritation made worse by the dry cabin air and enjoy the intricate quilting work she loves.

Dry eye disease is just one of a handful of eye conditions women need to be aware of as they move into middle age and beyond. Startling as it may seem, of the one million Americans who are blind, 700,000 are women. Worldwide, women make up two-thirds of those who are blind. (1) The fact that women on average live longer than men and are therefore more likely to suffer serious age-related eye conditions accounts in part for the higher prevalence of blindness among women. There are other contributing factors too, including a lack of education among women about blinding eye diseases, their causes and prevention, and a failure to use or have access to eye care services, especially among women in developing countries.

These facts shocked Harvard ophthalmology professor Ilene K. Gipson, PhD, when she read them last year. "No one knows this," says Dr. Gipson, who is also a senior scientist at the Schepens Eye Research Institute, an affiliate of Harvard Medical School, in Boston. So Dr. Gipson, along with several other ophthalmologists and eye researchers, recently formed the Women's Eye Health Task Force to spread the word about women's eye health.

"Not only do we want people to understand that there is this issue of prevalence of blindness among women, but we also want them to know that some of these diseases are related to nutrition, lifestyle and the environment," says Dr. Gipson. "In teaching women about that, then they as caregivers can influence the vision health of the entire population."

Considering Eye Health

Chances are, unless you're putting on mascara, popping in your contacts, or fumbling for your glasses, you don't think much about your eyes. But if you're hitting middle age or beyond, the health of your eyes should be as important to you as the health of your bones.

The eye is like every other part of your body--subject to the wear and tear of aging. And just as you search anxiously for that first gray hair, it's important that you--and your eye care professional--also keep your eyes pealed (pun intended) for those first signs of vision problems.

Read on to learn more about: symptoms of vision problems; how to prevent age-related eye conditions; why not to panic if you are diagnosed with one; and where the science stands on treatment and prevention.

Presbyopia 

You know you've got presbyopia when you find yourself bolding books and newspapers farther and farther away from your eyes, until you reach the point where you either have to give in and get reading glasses or figure out how to lengthen your arms. And you will get it: presbyopia affects virtually everyone eventually to some degree. (3)

Here's why: The lens, the transparent elliptical structure just behind the iris, normally changes shape (flattens and thickens) to focus incoming light from objects far away and near. In young people, the lens is extraordinarily elastic and flexible, but as we age, the lens gets less flexible and eventually gets rigid, making it difficult and ultimately just about impossible to see nearby objects clearly. By your 40s, you are likely to experience some symptoms of presbyopia.

So you start buying reading glasses. Though you may find it annoying, most people cope well with this solution. Or you may switch to bifocal contact lenses or glasses.

The growing field of refractive surgery (surgery to eliminate or decrease dependency on glasses and contact lenses) may offer one possible solution. A relatively new form of refractive surgery called conductive keratoplasty (CK), already approved to treat farsightedness, is being used to treat presbyopia, even though it isn't yet specifically approved by the U.S. Food and Drug Administration (FDA) for this purpose. During the three-minute office procedure, the non-dominant eye (everyone has one eye that is dominant, or stronger, than the other) is overcorrected, making it slightly nearsighted and creating a kind of bifocal out of your eyes--one to see far, the other to see near.

Long-term studies are still needed on the safety and efficacy of this procedure.

Diabetic Retinopathy 

Diabetic retinopathy is the leading cause of blindness in American adults. Nearly half of all people with diabetes will develop some degree of diabetic retinopathy during their lifetime. Yet many people with diabetes don't know about their risk for this disease. (4)

Diabetic retinopathy is caused by changes in the blood vessels of the retina. In some people with diabetes, the retinal blood vessels swell and leak fluid. In others, new blood vessels grow on the surface of the retina. In both cases, vision loss or blindness is a likely result. It's a sly disease, and your vision may not change until the disease becomes severe. (4)

People with diabetes are also twice as likely to get a cataract [explained on page 4] or develop glaucoma [explained below] as someone without diabetes, and are likely to develop cataracts at an earlier age. That's why it's so important that people with diabetes get annual eye exams.

The good news is that tight control of your blood sugar levels can prevent diabetic retinopathy, says Dr. Gipson. The Diabetes Control and Complications Trial (DCCT), a large, national study examining the effectiveness of tight blood sugar control on diabetes complications, showed that better control of blood sugar levels slows the onset and progression of retinopathy and reduces the need for laser surgery for severe retinopathy. (5)

Keeping your weight within appropriate ranges with your health care professional's guidance is also extremely important to diabetes management and eye health, says Dr. Gipson.

Otherwise, laser and retinal surgery offer treatment in many cases and the earlier the disease is diagnosed, the more likely the surgery can save your eyesight.

Glaucoma

You could be going blind and not even know it. That's the horror of glaucoma, the name given to a group of related eye diseases that is the second leading cause of blindness in the United States. (6) Glaucoma affects nearly three million people--only half of whom know they have it.

Although anyone can develop glaucoma, some are at higher risk than others. African Americans over 40, for instance, are six to eight times more prone to developing the disease, and once afflicted, are 14 to 17 times more likely than Caucasians to go blind. Additionally, Asian Americans have a greater risk of two forms of the disease than do Caucasians: closed-angle and normal tension. Other risk factors for glaucoma include: age (being over age 60), a family history of glaucoma, diabetes, severe nearsightedness, certain medications such as steroids used over a long period of time and previous eye injuries. (6,7)

Glaucoma occurs when the water-like fluid in your eye, which provides oxygen and nutrients to the lens and cornea, and which normally exits through a ring of drains located between the inside edge of the cornea and the iris, flows more slowly out of the eye because the drains become clogged. Pressure builds inside the eye in much the same way water pressure builds in a clogged garden hose. Unless this pressure, called intraocular pressure, or IOP, is controlled, it can damage the optic nerve and cause vision loss. Once enough nerve cells are destroyed, you begin to lose your peripheral field of vision.

There are several types of glaucoma, but the most common ones are primary open-angle glaucoma, or POAG, and normal tension glaucoma, also known as low-tension glaucoma.

The key with glaucoma is diagnosing it early, because the earlier it's diagnosed, the sooner treatment begins and the less damage occurs. But because there are no symptoms of glaucoma, only your eye care professional can diagnose it.

Treatment is simple, says Anne Sumers, MD, an ophthalmologist in Ridgewood, NJ, and a national spokesperson for the American Academy of Ophthalmology: one drop of medicine a day. Compare that to 17 years ago when she first started practicing and patients had to take up to 16 drops of several different medications a day, many with severe and dangerous side effects. Today, several prescription eye drops are available to treat glaucoma, all of which lower the pressure in the eye.

Cataracts

What's the most commonly performed surgery covered by Medicare? If you said open-heart surgery or hip replacement, you're wrong. It's cataract surgery--nearly two million such procedures are performed each year in the U.S. (8) Cataracts affect more than 20 million Americans age 40 and older. By age 80, more than half of all Americans have cataracts. (9,10)

Think of cataracts as the eye's equivalent of soapy windows. "The lens is a little bag of cells with a high concentration of soluble protein in them," explains Dr. Gipson. Cataracts occur when that protein comes out of the solution, similar to what happens when water evaporates from a saltwater solution, leaving crystals of salt. The lens gradually becomes opaque, so gradually you may not even know you have cataracts until you visit your eye care professional.

"A common first symptom people have is they feel like their glasses aren't clean," says Dr. Sumers. Other common symptoms of cataracts include sensitivity to glare, particularly at night while driving, and also worsening nearsightedness (myopia).

The good news is that correcting cataracts is simple, and they're one of the most curable eye diseases. (11) An ophthalmologist removes the clouded lens, replacing it with an artificial intraocular lens (IOL) implant. Dr. Sumers has found that her patients often are amazed at how bright colors are and how clear the world appears after she replaces their lens. Although there are several different types of cataract surgery, Dr. Sumers suggests you talk to your eye care professional about Topical Clear Corneal surgery. This procedure involves a topical anesthesia rather than injection, requires a much smaller incision and thus fewer stitches, and uses a foldable acrylic lens. "The smaller the incision, the safer it is," she says.

As for prevention? Wear sunglasses and quit smoking. Both ultraviolet light and smoking contribute to the early development of cataracts, says Dr. Sumers.

Age-Related Macular Degeneration 

Age-related macular degeneration (AMD) is the leading cause of vision loss in people over 65. (8) It affects an estimated 1.6 million Americans, most of them women. "It's an epidemic," says Dr. Sumers, "because people are living longer."

Macular degeneration primarily affects the part of the retina responsible for sharp central vision. Over time, people with the condition can be left with just their peripheral vision. While no one knows what causes the disease, new research suggests it may be the result of an "inappropriate" immune-system response related to an inflammatory disorder. (12)

There are two forms of AMD. Dry macular degeneration, which affects about 90 percent of those with the condition, occurs over years due to the presence of drusen, fatty deposits under the light-sensing cells in the retina. The most common early sign of dry AMD is blurred vision. As fewer cells in the macula (a small yellowish area of the retina where cone cells are most densely packed) (13) are able to function, people see details less clearly in front of them, such as faces or words in a book. Often, however, this blurred vision goes away in brighter light.

If you lose many of these light-sensing cells, you may see a small but growing blind spot in the middle of your field of vision. Vision loss progresses slowly, however. And eating a diet rich in zinc and antioxidants and/or taking supplements may slow the progression of age-related AMD, or even decrease your risk of getting it. (14) (See the Lifestyle Corner, page 8, for more information.)

The other form of AMD is wet macular degeneration. It occurs when new blood vessels grow into the macular, breaking and bleeding and causing very fast, severe vision loss. Therapy includes laser treatment to break tip the blood vessels and limit the damage, but only a few patients are eligible for this surgery.

The classic early symptom of wet AMD is that straight lines appear crooked. This results when fluid from the leaking blood vessels gathers and lifts the macula, distorting vision. A small blind spot may also appear in wet AMD, resulting in the loss of your central vision.

For more information on dry eye disease and other eye conditions, visit www.healthywomen.org.

HOW THE EYE WORKS

[ILLUSTRATION OMITTED]

When light first enters the eye, it must pass through the tear film, which is like a reflecting mirror. Then the light passes through the cornea, then through the pupil, an opening in the iris, and on through the lens and the vitreous humor (the fluid that helps maintain the eye's shape and nourishes the cornea and the lens) to the retina. The cornea, lens and vitreous humor are where light is refracted (bended) in the eye. The elastic lens curves and reshapes itself in order to focus light rays in the retina, where they stimulate the rods and cones, the sensory receptors. The rods and cones take visual messages to the brain via the optic nerve. (2,3)

Questions to Ask Your Eye Care Professional.

1. Do I need glasses? If so, why? (For nearsightedness, farsightedness, presbyopia or other eye disorders?)

2. Do you see any signs of problems in my eyes, such as cataracts, age-related macular degeneration (AMD), glaucoma, dry eye or other eye diseases?

3. Are there any medical conditions, such as diabetes, hypertension, or high cholesterol, that I should be concerned about because of anything you noted during my eye exam?

4. When should I return for a follow-up exam and when should I have my pupils dilated for a full exam of my retina?

5. Are there any diseases for which my family is at risk, such as AMD, genetic eye disease or glaucoma?

Source: Women's Eye Health Task Force, Schepens Eye Research Institute.

Resources

American Academy of Ophthalmology

PO Box 7424

San Francisco, CA 94120

415-561-8500

http://www.aao.org

Provides consumer information on eye health and disease, plus referrals to eye specialists.

Lighthouse International

111 East 59th Street

New York, NY 10022-1202

1-800-829-0500

http://www.lighthouse.org

A worldwide resource on vision impairment and vision rehabilitation, providing education, research, advocacy and rehabilitation.

National Eye Institute

2020 Vision Place

Bethesda, MD 20892-3655

301-496-5248

http://www.nei.nih.gov

Part of the National Institutes of Health, the NEI provides information on eye diseases and disorders, including clinical trials, and low vision aids.

Prevent Blindness America

500 East Remington Road

Schaumburg, IL 60173

1-800-331-2020

http://www.preventblindness.org

A volunteer organization dedicated to eye health and safety that provides information on eye diseases and conditions, as well as tips on eye safety, children's eye health and links to news and resources.

The Sjogren's Syndrome Foundation

8120 Woodmont Avenue

Bethesda, MD 20814

1-800-475-8473

http://www.sjogrens.org

Provides patients and the general public with information about the disease and resources to aid people living with Sjogren's.

Women's Eye Health Task Force

http://www.eri.harvard.edu/wehtf

The WEHTF is dedicated to educating people about eye diseases that are prevalent in women and the gender, lifestyle and environmental issues responsible for them.

Dry Eye Disease

Vicki Slone will never forget the morning she woke up with a searing pain in one of her eyes. Her ophthalmologist later told Ms. Slone her eyes were so dry that her eyelid had stuck to the surface of the eye during the night, and when she opened her eyes in the morning she tore the cornea.

Ms. Slone is one of the nearly 3.2 American women over age 50 who have dry eye disease. The condition affects women two to three times more often than men, with Hispanic and Asian women more likely to be affected."

Why women? Blame it largely on hormones. Hormonal changes associated with aging, pregnancy, menopause and autoimmune diseases such as arthritis, lupus and Sjogren's syndrome can cause dry eye disease. Medical conditions such as diabetes and blocked tear ducts also can lead to dry eye disease.

In terms of aging, as women grow older, their production of the male androgen (sex hormone), testosterone, drops. More commonly thought of as "the libido hormone," testosterone also plays a critical role in maintaining the tear-making gland called the lacrimal gland. As testosterone levels drop, levels of chemicals called cytokines rise, leading to inflammation. Once the lacrimal gland is inflamed, it slows the release of tears.

Dry eye disease is not simply a problem of a reduced amount or lack of tears. The main functions of tears are to lubricate the eyes and protect them from bacteria and environmental irritants such as dust. This requires both the right amount of tears and a balance of the many components that make up tears. Without the right quantity or quality of tears, dry eye disease may develop.

Dry eye disease can be made worse by dry indoor air, contact lenses and car air conditioning vents aimed at the face for prolonged periods of time. Also, some medications can cause dry eye symptoms. Ask your eye care professional or your pharmacist if any of the medication you take has a drying effect on the tear lake.

Until recently, there were just two treatments for dry eyes: over-the-counter artificial tear eye drops designed to replace your natural tears, or a non-surgical procedure called punctal plugs in which tiny bits of silicon are inserted into the openings on the lower and upper lids where tears drain into the nose. Plugging these openings keeps the tears in the eye and helps prevent your eyes from drying out.

But in April 2003 the first U.S. Food and Drug Administration-approved prescription treatment for dry eyes, Restasis (cyclosporine ophthalmic emulsion 0.05%), became available. This treatment increases the body's ability to produce its own natural, healthy tears by treating the underlying cause of the disease--inflammation, says Marguerite B. McDonald, MD, FACS, clinical professor of ophthalmology at Tulane University School of Medicine in New Orleans, LA.

Not everyone will need a prescription for dry eyes, notes Dr. McDonald. "However, if you're using artificial tear eye drops frequently without getting long-term symptom relief, you might want to consider asking your eye specialist about Restasis," she suggests. Otherwise, you're fine with over-the-counter artificial tear eye drops.

But check the labels carefully. Artificial tear eye drops differ from redness-relieving eye drops. The latter provide only a cosmetic benefit: removing the redness.

Additionally, artificial tear eye drops come in two forms: with and without preservatives. Many people are sensitive to preservatives in artificial tear eye drops, making using them intolerable. Look for brands without preservatives, if your eyes are especially sensitive.

Do You Have Dry Eye Disease?

Review the following symptom checklist to determine if you might have dry eye disease. Ask your eye health specialist for more information:

* Sensitivity to light

* A gritty feeling in your eyes

* Eye pain and eye redness

* Itching or burning eyes

* Eye irritation made worse by dry air, wind, or air conditioning

* Blurred vision that improves with blinking

* Excessive tearing

* Increased discomfort after periods of reading, watching TV, driving at night, or working on a computer.

Eye Health Questions & Answers

Q There are so many different eye care professionals--optician, optometrist, ophthalmologist--how do I know which one to see for what?

A Basically, your optometrist and ophthalmologist can cover all your eye health needs. He or she can fit you with glasses or contact lenses, screen you for glaucoma, cataracts, macular degeneration and other eye conditions, and if you have dry eye disease or glaucoma, treat you for it.

However, only ophthalmologists can perform eye surgery.

If you need glasses or contacts, optometrists and ophthalmologists can write a prescription for an optician to fill, but the optician can't give you glasses without a prescription. Many optometrists and ophthalmologists have opticians working with them in their offices.

There are also specialty ophthalmologists, such as retinal specialists who correct retinal detachments and perform laser treatment for wet macular degeneration; neuro-ophthalmologists who take care of people with strokes in their eyes and other neurologically related eye diseases; oculoplastic surgeons who treat cosmetic and age-related lid disorders as well as tear drainage problems; and pediatric ophthalmologists, who specialize in treating children.

Q How often should I see an eye care professional?

A The American Academy of Ophthalmology guidelines state that all children should see an ophthalmologist before entering kindergarten and that if everything is fine, the child doesn't need to go back unless the school or parents notice a problem. Adults 40- to 65-years-old should see an ophthalmologist once every two years. Those with a family history of eye disorders may need more frequent office visits. Adults 65 and older should see an eye care professional once a year.

--Anne Sumers, MD

National Spokesperson

American Academy of Ophthalmology

Ridgewood, NJ

Q I have dry eyes and use a lot of artificial tears. What is the best way to put eye drops in so they go in my eye, not all over my face?

A It's critical not to touch the bottle or the tip of the dose dispenser to your eye or eyelashes. Try to drop the liquid into your eye from two inches up in the air. In the beginning, you'll waste a lot, but eventually you should improve. Some people never get good at it and have to ask a friend to put drops in. Some people have to lie down to get the drops in because they have arthritis in their necks and can't lean their head back far enough.

--Marguerite B. McDonald, MO, FACS

Clinical Professor of Ophthalmology

Tulane University School of Medicine

New Orleans, LA

References

(1) Abou-Gareeb I, Lewallen S, Bassett K, et al. Gender and blindness: a meta-analysis of population-based prevalence surveys. Ophthalmic Epidemiol. 2001 Feb; 8(1):39-56.

(2) Ledford, JK and Pineda, R. The Little Eye Book: A Pupil's Guide to Understanding Ophthalmology Thorofare, NJ: Slack incorporated, 2002.

(3) "Presbyopia." Medline Plus Health Information. http://www.nlm.nih.gov/medlineplus. Accessed August 2003.

(4) "Are You at Risk for Diabetic Eye Disease?" National Eye Institute http://www.nei.nih.gov. Accessed September 2003.

(5) Retinopathy and nephropathy in patients with Type 1 diabetes four years after a trial of intensive therapy. The Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications Research Group. N Engl J Med 2000 Feb 10;342(5):381-9. Erratum in: N Engl J Med 2000 May 4;342(18):1376

(6) "What is Glaucoma?" Glaucoma Research Foundation. http://www.glaucoma.arg. Accessed August 2003.

(7) "Facts About Glaucoma." National Eye Institute. http://www.nei.nih.gov. Accessed August 2003.

(8) Quillen DA. Common causes of vision loss in elderly patients. Am Fam Physician. 1999 Jul;60(1):99-108. Review.

(9) The Statistics; Women's Eye Health Task Force. http://www.eri.harvard.edu/wehtf/cataract.html

(10) Vision Problems in the U.S.: Prevalence of Adult Vision Impairment and Age-Related Eye Disease in America. National Eye Institute. http://www.nei.nih.gov. Accessed August 2003.

(11) "What is a Cataract?" Women's Eye Health Task Force. http://www.eri.harvard.edu/wehtf/cataract.html. Accessed August 2003.

(12) Anderson DH, Mullins RF, Hageman GS, Johnson LV. A role for ideal inflammation in the formation of drusen in the aging eye. Am J Ophthalmol. 2002 Sep;134(3):411-31. Review.

(13) Quick Reference Dictionary of Eyecare Terminology. Third Edition. Thorofare, NJ: Slack Incorporated, 2002.

(14) The Age-Related Eye Disease Research Group: A randomized, placebo-controlled, clinical trial of high-dose supplementation with vitamins C and E, beta carotene, and zinc for age-related macular degeneration and vision loss AREDS Report No. 8. Arch Ophthalmol 119: 17-1436, 2001.

(15) Schaumberg DA, Sullivan DA, Buring JE, Dana MR. Prevalence of dry eye syndrome among US women. Am J Ophthalmol. 2003 Aug;136(2):318-26.