Per aspera ad astra – Through hardships to the stars

According to the latest data by the World Health Organization, there are approximately 36 million blind people in the world, and the numbers keep growing due to increasing population sizes in developing countries and rising life expectancies in developed nations.

The most frequent cause of blindness in the world is cataracts (accounting for about 51% of cases), however, in Europe and other economically developed regions it is age-related macular degeneration (AMD), which affects up to 20% of the population older than 80 years. Diabetic retinopathy and primary open-angle glaucoma represent the second- and third-most common causes of sight loss.

There have been huge developments in the way cataracts are treated in the past 30 years. Cataract surgery used to be a relatively risky operation, involving many days of hospitalisation and permanent usage of reading glasses with more than 12 dioptres and many postoperative complications.

However, this surgery has become much safer and is now conducted in outpatient care and with topical anaesthesia, often with no need for the patient to wear any glasses.

Today, it is not uncommon to see 90-year-old ladies reading a menu or bus timetable without glasses. These outstanding results are due to progress in technologies, progress that continues to give rise to new surgical methods and novel lenses.

Nonetheless, should we not rather invest more finances in basic research into preventing diseases or developing new therapies for diseases whose treatments are not currently successful enough, such as AMD?

Is it really necessary to operate on patients with dysfunctional lens syndrome? Should this procedure be paid for by health insurance? What kind of lenses should be publically funded?

And do we really need to operate with increasingly sophisticated and expensive devices if the results with our current devices are already excellent?

The treatments for neovascular AMD (nAMD) and diabetic macular oedema have been long unsuccessful in comparison with the great achievements that have been made in treating anterior segment disorders and diseases.

For many years after I started my career in ophthalmology in 1974, a patient diagnosed with senile disciform macular degeneration, or Kuhnt-Junius degeneration disease, as nAMD used to be called, was said to be in risk of “only” losing his central vision; that is, he would not be able to read and recognise familiar faces, but complete blindness would not be imminent.

The results of macular photocoagulation, the most commonly-used method with such retinal disorders, were not satisfactory at all.

Thankfully, times have changed, with vascular endothelial growth factor (VEGF) being discovered in 1989 and the introduction of intravitreal applications of anti-VEGF drugs following, in 2005. The success rate of this therapy in patients today is almost 90%. Meanwhile, retinal prosthesis implants offer hope to patients with late-stage AMD who no longer respond to therapy.

However, there is still so much work to do. We need to invest much effort and substantial funding into the areas of gene therapy and stem cell transplantation with retinal disorders.

Technology keeps outperforming us, and not only in ophthalmology. Stephen Hawking claims technology will be one of the main causes of our extinction. Do we need femtosecond laser–assisted cataract surgery? Do we need ‘super vision’?

I am certainly not against progress, but I know that top-notch technology has the power to enchant the surgeon and thus negatively affect their ability to act responsibly. 

E-mail: kuchynka@fnkv.cz

Professor Kuchynka is professor of ophthalmology at the Vinohardy Teaching Hospital, Prague, Czech Republic. Dr Kuckynka is a member of the Ophthalmology Times Europe Editorial Advisory Board.