How to Improve Your Eye Health & Offset Vision Loss | Dr. Jeffrey Goldberg

welcome to the huberman Lab podcast where we discuss science and science-based tools for everyday [Music] life I'm Andrew huberman and I'm a professor of neurobiology and Opthalmology at Stanford school of medicine today my guest is Dr Jeffrey Goldberg Dr Jeffrey Goldberg is the chair of the Department of Opthalmology at Stanford University School of Medicine he is a clinician an MD or medical doctor who sees patients every week as well as a PhD meaning a laboratory scientist who directs his own laboratory focused at understanding the mechanisms and cures for diseases of the eye EnV Vision such as glaucoma retinitis Pigmentosa and macular degeneration indeed Dr Goldberg is one of the world leaders in developing methods to cure blindness he is also intensely knowledgeable about all things related to Vision so during today's discussion we indeed cover most all of visual and Eye Health you will learn for instance about the benefits as well as draw backs of wearing corrective lenses such as contact lenses or eyeglasses for reading you will learn about the benefits and detriments of sunlight meaning how it can help your vision in fact how it can help reverse or prevent myopia nearsightedness as well as the things to be cautious about with respect to sunlight in terms of development of cataracts which are occlusions that prevent Vision we also discuss many tools for maintaining and improving Vision across the lifespan r ranging from behavioral tools so specific Vision tasks and exercises for the eye that you can do that are known to improve or maintain your vision as well as specific surgical procedures such as lasic surgery we get into all the details of for instance how often to do these various eye exercises how long the benefits are maintained as well as age related considerations for things like lasc eye surgery we even get into how to best clean your contact lenses whether or not to use disposable contact lenses or other forms of contact lenses we also discuss things like dry eye and the best remedies for dry eye and we talk about the scientific and clinical data around nutritional approaches and supplementation based approaches for maintaining and improving Vision so whether or not you suffer from floaters or dry eye or you're considering changing your eye prescription or you have concerns about whether or not relying on corrective lenses is impairing your vision and you want to enhance your vision or if you're somebody who has perfect vision today's episode is going to include science and protocols that will be highly relevant to you I should also add that if you are somebody who suffers from or who has family members who suffer from diseases of the eye that can impact Vision such as glaucoma retinitis Pigmentosa and macular degeneration we also delve deep into the discussion about the most Advanced Technologies for preventing and offsetting vision loss due to those diseases as well thanks to Dr Goldberg's incredible knowledge his Clarity of communication and his generosity with that knowledge by the end of of today's episode You Will Be armed with all of the modern information you need in order to best maintain and improve your eye and vision health before we begin I'd like to emphasize that this podcast is separate from my teaching and research roles at Stanford it is however part of my desire and effort to bring zero cost to Consumer information about science and science related tools to the general public in keeping with that theme I'd like to thank the sponsors of today's podcast our first sponsor is Maui Nei venison Maui Nei venison is the most nutrient dense and delicious red meat available I've talked before on this podcast about the key importance of striving to get 1 gram of protein per pound of body weight now when one strives to do that it's also important to maximize the quality protein to calorie ratio in other words you don't want to consume a lot of extra calories in order to get your quality protein 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discussion about all of that but I'm really excited for today's discussion because I get a tremendous number of questions about vision and I health and of course as a neuroscientist who has worked on the visual system I sometimes have answers or partial answers but more often than not I don't have the answers and yet I'm confident that you do or that if you don't you can direct us to the place to get those answers so to kick things off I want to ask you what was one of the most commonly asked questions when I solicited for questions in anticipation of this episode which is how early should one do an eye exam on their child and how regularly should we all be doing eye exams also is the fact that I think I can see normally confirmation that I can see as well as I think I can so that's really three questions but baby comes out do they check their eyes right away and if so how and how often should they check and what kind of information is there yeah it's as it's a great question it's obviously something that touches us all so the qu the answer to that really differs a little bit uh at the different stages of Life first of all every every baby gets an eye exam or should be getting an eye exam and uh one of the main things that you really just are screening for right when that baby is born right in the nursery right in those first few days is to just look for a red reflex you know when you take a camera picture a Flash picture and sometimes you get red eye that's actually the light from the flash as you know reflecting against the retina and coming back out of your eye it looks red and um and a red reflex is actually very normal that's that that's great and if you have a one of a number of diseases in the eye that can present even in babies even in newborn babies including most concerning but thankfully least Comm retinoblastoma which is the most common pediatric eye cancer uh which again thankfully is quite rare uh those babies won't have a red reflex in that eye it'll be kind of a whitish or gray reflex and so even just that first little you know doctors taking the little pen light and even just flashing it in the in the baby's eyes so that's that's that's our first eye exam and and hopefully we've all had that and hopefully every baby being born today is getting that getting that first eye exam is really just looking for for that red reflex uh it's not typical as long as that's looking good um to worry about getting an i exam from there kind of through um childhood like uh maybe early Elementary School unless they B your baby is presenting with one of a number of features that parents often pick up on for example as the baby's aging through those first couple of years you know through the first couple of years babies actually don't have great visual Acuity and so as they're aging over those first couple years it's normal for them to have you know roving eye movements for example be searching their environment um but over those first couple of years if parents start noticing the baby isn't you know isn't uh making eye contact or looking where a sound is certainly if they have what's called nagus like these rapid flickering alternating eye movements uh anything like that of course you're going to trigger trigger an eye exam but otherwise most babies other than their pediatrician doing that red reflex check when they're in for their regular well child checks uh that's really all that's uh needed through that when most kids get to elementary school age there will often be often done at the schools an amblyopia screening exam if kids eyes either if one eye doesn't see that well like maybe you're very nearsighted or farsighted in one eye and pretty normal sided in the other or the two refractive errors are quite different from each other other um that can lead to a condition you've talked about on the podcast before called amblyopia uh which is probably one of the more common or most common eye diseases of children or uh if the eyes aren't aign you know our eye muscles and the Brain behind them are really responsible for keeping the two eyes looking straight ahead and if that's not working properly and one eye is is off-kilter and therefore the image of what we're looking at is falling on different spots of the retina it's not sinking upright in the brain that can lead to this disease condition called amop where that eye is no longer talking to the brain properly and there's a pretty easy screening exam that can be done for strabismus the misalignment of the eyes that kids will do in elementary school the other main presenting symptom if kids in elementary school is when they admit to their parents I can't see the board or I can't see the teacher up front and then they might be quite nearsighted and so that will also trigger an exam and uh so those are usually the parts for for babies for toddlers for children schoolage children that might reasonably trigger an exam a couple of questions about early eye exams and we'll um get on to uh ey exams in older individuals in a second um but I want to interrupt you with this question so you mentioned that um you know there can be a misalignment of the eyes I've seen many people's babies where there is one eyeball that seems to be kind of drifting around and then it might correct but sometimes they'll have a we don't want to get technical here but for our listeners we'll keep it General but they're conver convergent eyes or one eye converging cross eyes or walyed you know again using uh that non-technical language here um and my understanding is that the brain is taking that information in and is very plastic it's changing at these early stages of development and that it's fairly critical to get that stuff corrected early on because if you wait too long the brain can essentially become blind to the the um or rather the the brain cannot learn to handle the proper alignment so in other words if a kid has cross eyes um crossed eyes excuse me and they're not corrected uh until their 20s it's possible that they will never recover normal vision whereas if you recover if you align the eyes properly early in development they can indeed recover Vision how early can and should one consider getting those eye realignments done yeah yeah pretty much right on what they'll do is if they detect any eye misalignment and sometimes parents are are good at noticing that sometimes you take a picture and one eye got the red eye reflex and the other one didn't and sometimes people notice that their kids eyes are sort of turning in it seems like too much um sometimes there's what's called pseudo stabismus which is where actually depending on your Anatomy if you have a little extra skin sort of on the inside corners of your eyes it makes your eyes look turned in when actually they're straight um but if your eyes are actually turned in or slightly less common in children more common in adults this alignment turned out um it's really important to correct that early and the reason is as you were saying the brain starts ignoring it it fails to fully develop the strong connections from the for the data coming in from one of those two eyes into the brain and if you pass certain sort of thresholds during development during childhood without correcting that connectivity getting those two eyes to work together properly um you can permanently lose that um and so we use sort of we used to use very sort of uh you know gross numbers like it's fully correctable if you can intervene before age three it's partly correctable if you can intervene before age six you got a chance before age nine but it turns out in followon studies that even kids into their young teens have a shot at correcting that eye brain connection that amblyopia that that loss of vision uh that that can occur during early development so even if you're only you know unfortunately detecting that later on in childhood or even sort of the tween years or early teen years it's still worth a try to really push to um retrain the weaker eye and then also realign the muscles so that they can work together to keep the eyes focused I'll tell you it's interesting and there's a lot more to learn about BL brain plasticity and probably a lot of really cool new therapies yet to discover that could reopen what's called critical period plasticity this this this plasticity that we have during development that kind of goes away as we age and and that critical period plasticity as you know has been the best studied actually in the visual system and the idea that we could reopen that is really fantastic but for different parts of that ibrain connection there's different periods for critical period plasticity for example even if you get the amblyopic eye to see well again and then you realign the eyes and now they're working together a lot of kids will never recover full depth perception stereopsis the use of two eyes to see depth for example so why that part of the brain doesn't correct as well as the visual Acuity or central vision part of the brain I'm not sure if we understand that yet I'm gonna ask for a curbside consult as uh it's sometimes called right now by telling you a story when I was a kid I went swimming without goggles and I had one eye closed and the other eye open and closing as it went in and out of the water because I'm a deficient swimmer and I only breathe to one side unless I really consciously forced myself to breathe to both sides in a freestyle swim got out of the pool and I was seeing double it was pretty eerie and then it became downright scary because I didn't recover my double vision until they patched one of the eyes forcing me to used the other eye that had been closed the entire time and fortunately this was done early enough and it I was young enough that within I think it was about a day or so I restored what normal vision however my depth perception is terrible um I'm the kid that you know Fly ball was hits me in the Outfield and it's coming it's coming then it would hit me this is why I've generally focused on foot Sports throughout my entire life as opposed to you know precise um hand eye coordination I'm better at throwing darts things with one eye closed than I ever would be with both eyes maybe that's true for most people question I have is is it true that even just a few hours of misalignment of information to the two eyes early in development can permanently rewire the brain unless there are some corrective measures such as patching up one eye um and the example I gave is just one but for instance if um uh you know someone injures you know gets a scratch on their cornea and they close they patch eye and the person happens to be 10 years old is it important to then patch the other healthy eye after the the um you know the the scratched eye is feeling better in other words how critical is it to ensure the balance of information coming into the two eyes even on the order of hours or days yeah your story is uh has some features of uh you know totally usual how we think about misaligned eyes leading to amblyopia where one eye is weaker patching the strong eyes to the weak eye can recover but not necessarily fully regaining depth perception and so that part of it is you know quite stereotypical the part of your story that's atypical is that for most kids um an hour or two let alone minutes an hour or two even an hour or two a day if you were I don't know if you were a young kid and you just really were training up on throwing darts and you were just keeping one eye closed to throw the darts you know really practicing for an hour or day it'd be very unusual for that to trigger this kind of either stabismus misalignment of the eyes let alone amblyopia uh and the stabismus is what's giving you the double vision because they're misaligned let alone the am amblyopia of one eye turning out weaker if I had to guess of course not having you know done your exam before that fateful day in the swimming pool if I had to guess I would guess that you may have had some intermittent strabismus and your brain was already getting kind of hit and and you neither you nor your parents may have even noticed it it could be happening you know at other times a day or you're not kind of really paying attention it doesn't kind of stand out in the way that that that day that that you got out of the swimming pool you really noticed it and it may not have been that strong it may have been quite intermittent but if you had had some years of intermittent esotropia or turning in of the eyes or exotropia turning out of the eyes that just happened here and there but was accumulating sort of uh damage or failure to connect over years leading up to that day in the swimming pool and that day just tipped you over the edge and you've got double vision you really noticed it that led to an eye exam at an eye care provider and they said wait a second this eye is stronger this ey is weaker you've got a little ellopia we're going to start patching your strong eye so you can get your weak eye back so for 99.99% of the kids who like you know yeah they get a little corneal scratch or they're patching one eye closed or or uh you know and anything that's sort of a rare event like that nothing to worry about parents don't have to worry kids can be kids they can play they can do that kind of thing and uh and not have to worry and and it's unfortunate that we can't tell in advance which kids been having the intermittent amop because we don't do a standard eye exam on every five-year-old who's not complaining of anything but but yeah so that's that's an unusual case in yours and if I had to guess I I would bet that you were having some sort of subclinical untracked Uncharted unnoticed maybe strabismus leading up to that point okay great thank you you can send me a bill at the end um along those lines I'm 47 years old so I was um part of the generation that grew up with some computers in the classroom but not a lot uh nowadays kids from a very young age are looking at iPads and phones and screens and things very close up and there is a wealth of experimental animal data showing that if you limit Vision to just close range that the eyeball lengthens and therefore the visual image Falls in front of and not directly onto the neural retina the essentially the light sensing portion of the of the eye and those animals become myopic or nearsighted what can we say about the environmental conditions in which kids are seen from the time they're born through let's say adolescence and their teen years in terms of how their visual system wires up and are there any recommendations that are coming from the scientific literature clinical studies clinical trial excuse me or otherwise that indicate what a healthy visual environment consists of yeah yeah that's a great question and actually it's really relevant these days because uh you know myopia is so common uh it's more common um in Asian populations you know it's called an epidemic in China uh in California we have a lot of Asian Heritage or asian-americans and so we see a lot like at Stanford we see a lot of um you know myopia in kids and adults and really starting to get thoughtful on the science of myopia control how do we how do we we provide the right environments now what's interesting is that for decades the Assumption some of the data really led us to the path of thinking like gosh the more you spend at near activities and these are Mouse model experiments like you describe but also well-designed human cohort studies you know figuring out like asking you know kids and families like how long is your kid reading or in front of the computer how myopic are they how nearsighted are they versus how much time is your kid in front of the computer doing near work how myopic or nearsighted are they and these well-designed cohort studies did Point towards this concept that if you do too much near work as a kid that you're more likely to develop nearsightedness as you get through those those sort of you know uh pre-teen and even into the teen years which is when most of that myopia progression or eyeball elongation is actually happening to cause nearsightedness it's only been in the last few years that some really exciting Studies have actually pointed in a slightly different direction and that's that maybe it's not all not to say it's not about near activity but maybe it's not all about near activity maybe it's actually a little more about the kind of light we're getting into our eyes and I think you've talked about this before and it's really important when they've now studied and asked the kids instead of just how much near and how much far are you doing how much time are you spending indoors in indoor lighting which doesn't have full spectrum light in a typical indoor environment versus how much time are you spending Outdoors playing in the yard you could be reading outside but what are you what what kind of time are you spending outside and and and of course when you're outside in sunlight even it's in direct sunlight you're getting a different spectrum of kind of Full Spectrum Lighting from the sun and it looks like it's pretty clear now actually that it has maybe more to do with outdoor lighting time than just near work and so I think that you know we we've we've actually already seen the first couple randomized controlled trials where they're having kids intentionally spending time Outdoors versus sort of Standard Life which you know is going to be often much more indoor time and uh and seeing some effects you follow those kids over a couple of years and the kids who spend time Outdoors are are progress dressing in their nearsightedness less like their their nearsighted prescription is not getting as strong as the kids who are spending more time indoors and there's some pretty good biology that's getting worked out going back to animal models more about about how that might be working in the retina in this inside the eye uh but it's pretty compelling uh concept and and so you know as a parent uh you you may want to be you may want to be telling your kid like okay yeah I want you to read that book or you you know if your kids playing on the phone or something like that or the iPad or something like that they're allowed that time okay you can have that time but I want you to spend some of the time that you're doing that Outdoors are there any thresholds for the amount of time that uh one would suggest their child be outdoors um to get that full spectrum light that's a great question you know we talk about cohort studies where we just ask people what are they doing and there seems to be you know a little bit of what we would call a dose dependent response maybe the more time Outdoors might be better we don't know if there's an upper limit like gosh if you go over 2 or three hours there's no additional benefit talk about that in cohort studies the real gold standard for answering these kinds of questions are randomized control trials and specifically Placebo controlled or or a control group that's not getting the intervention that's our highest level of evidence for clinical evidence for for any of this kind of science uh when we're talking about humans or preclinical models in the laboratory and the study that hasn't been done yet to really answer that question is to randomize kids to telling this group of kids you just do your normal life tell this group of kids we want you outside an hour this group of kids we want you outside two hours a day this group will K three hours a day and see between the groups is there a big difference like we have pretty good evidence now from the studies that have been done that the difference between zero and one or two hours is clearly there is 5 minutes enough is 5 hours better I don't think we know the answers to those questions yet like what's the right dose um but there's probably at least some dose dependence to that and it I can imagine it's a little bit hard to tease apart the near far viewing from the indoor outdoor because yes of course a child could be outside on an iPad up close but it's hard to imagine that at some point they aren't seeing off into the distance far viewing as it's called and reverse is also true if you're indoors unless you live in a very very large home or you're staring off a balcony far viewing is much harder to achieve yeah yeah so it's and perhaps it isn't important to isolate these variables although I can see the challenge in developing a really good clinical trial randomized clinical trial for this meanwhile I I you know I'm con I'll go into the grave shouting you know or saying rather and suggesting that people get some morning sunlight in their eyes to set their circadian rhythm um but far viewing a few at least a few minutes and ideally hours per day or a mixture of near and far viewing by being outdoors just seems like a good thing to do regardless of age so are there any data in older people not necessarily elderly but older people so um people in they from say 25 years of age into their 60s or 70s that getting outdoors and getting this full spectrum light is healthy for the eye in ways that are separate from the known healthy effects of doing that on circadian rhythm setting yeah yeah the cadium Parts pretty clear the in most patient in most in most people the near the development of nearsightedness happens a lot until age 10 little more through age 20 little more than that into the in you know in through the 20s up to 30 tiny bit in the 30s up to 40 but usually by those later ages your prescription might be changing a quarter of a diopter that's the measurement that we use when we you know give you your glass glasses prescription a quarter of a diopter half a diopter it could get a half diopter more nearsighted or less nearsighted you know once you're aging into your 40s 50s and Beyond so most of the action on nearsightedness development is actually really happening in the younger ages so again the the premise of intervening in an older person and I'll just include you and me and older people for the sake of this definition as much as I'm reticent to do that in general um I think the the the premise of in of a of of sort of light modulation for nearsightedness in older people is probably probably not so strong I think there are a lot of other benefits you've talked a lot about circadian rhythm there are so many health benefits to exercise and you know if you're getting Outdoors there's a good chance you're going to be walking or bicycling you know so so exercise value for the health of our eyes and the rest of our body is clearly there um but I don't know that there's really a strong premise that you're going to change your glasses prescription you know in our 40s or 50s or or Beyond I'd like to take a quick break and acknowledge one of our sponsors athletic greens athletic greens now called 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up athletic greens while you're on the road in the car on the plane Etc and they'll give you a year supply of vitamin D3 K2 again that's athletic greens.com hubman to get the five free travel packs and the year supply of vitamin D3 K2 it's probably worth touching on some of the dos and some of the don'ts for I Health generally uh and then I promise I'm going to get us back to adult eye exams um because have a lot of questions about that I can imagine that it's probably not a great idea to be exposed to extremely bright light and this is why people who weld wear eye Shields um but of course most people are not welding um what other sorts of environmental conditions are detrimental to our vision health across the lifespan um including brightness of light uh we talked a little bit about near far um obviously we want to keep toxins and acids and solvents and things out of the eye but what do you see I'm hopefully not commonly but what are some of the things that you feel might not be discussed enough in terms of Eye Health yeah you know I think at all ages eye safety is something that we don't talk about enough um you know our eyes are delicate the front surface of the eye the cornea the Clear Window that lets the light go into your eye that's a delicate very sensitive structure it's thin maybe a millimeter at the thickest half millimeter in the center of our eye uh the retina is it it's neural tissue this is like really an outgrowth of the brain this is very sensitive it's subject to degenerative disease and injury our eyes even if they just get hit can get very inflamed our eyes can be more inflammatory than a bruise on our skin on our shoulder might be so I safety is a big one and people who are um working in certain industries um you know anyone who's doing any metal grinding people who are even just gardening you know and if you're if you're doing some significant gardening and cutting and you could you know Fleck a little bit of dirt and there's a lot of there's a lot of for example fungus that lives in the ground natural stuff it's all very normal in the in the Earth but you know our eyes aren't really made to absorb that fungus and and have have a piece of dirt kind of stick in our eye like that and so people are at risk I think for you know for not and we see too much kind of really unnecessary eye injury eye trauma that if people wore either their glasses because they happen to wear prescription glasses or goggles or for more advanced work you know safety goggles of course um if you're sanding doing wood shop projects anything like that sawing including you know again in the garden cutting things um you know I think I think eye safety you know eye trauma is a big one and you know we probably see one or two um what we call open Globes a week come into the Opera uh into the emergency room and um you know those are tough because you know again the eyes delicate and it can do a lot of healing but but not infinite right and so we really you know that's that's one that I think is really an untapped opportunity is just a little more education around um around eye protection protecting against eye trauma what about eye cleanliness there's some pretty dramatic videos also um I've put some of these on my Instagram handle these are MRIs of people rubbing their eyeballs and people really getting a sense of first of all a restatement of what you said getting a real sense of just how much the eyes are in outgrowth of the brain because of the op when you see them with the optic nerves and all their beauty and the eyeballs moving around as someone rubs their eyes I have to imagine that rubbing the eyeballs a little bit as IM but I actually called you I don't know if you remember when I was a a junior Professor I woke up from an app one day and I couldn't see had of one eye I was freaking out so of course I called you and I had pressure blinded Myself by falling asleep on my hand or something like that and you assured me that my vision would come back and indeed it did so you played dual role of opthalmologist and psychiatrist thank you and indeed I can see out of both eyes um now um but rubbing our eyes getting gunk our eyes you know I think unless somebody has lost their Vision temporarily it's hard to imagine this is like a big deal but when it happens it is truly frightening we're so dependent on Vision so um you know what are your recommendations about rubbing or not rubbing eyeballs about um hand washing and cleanliness and also how do you wash an eye properly do you use soap and flush it with water or do you just flush it with water or she not even do that she use saline and realize these might sound like low-level questions but these are the things that people deal with on on an all too frequent basis yeah you know for most people most of the time actually the eyes are a very good clean environment and actually our tears are are contain enzymes that help break down bacteria and bacterial toxins and so for most people regular eyew washing doesn't have to be any part of their standard routine in terms of the surface of the eye the part of your eye the conjunctiva uh over the whites of the eyes underneath the eyelids anything underneath the ey it's pretty self-cleaning and actually our tear production and blinking is very good at keeping our eyes clean uh the eyelids eyelashes can be another story and especially as we age uh we can you know like our skin is breaking down a little differently than when we were younger you can develop what we sort of nickname scurf which is like kind of little dead skin bits that accumulate around the eyelashes a lot of people develop what we call blefaritis which is just just means inflammation of the eyelashes yeah and for that doing some eye scrubs is a good idea they actually sell uh little pads that you can buy kind of a little that you rip open and you can use to kind of lightly clean the eyelashes uh but you can also just use like a No More Tears baby shampoo just pump a little bit into the palm of your hand once or twice a day uh let a little uh dilute it with a little water under the sink and either with your finger or an edge of a washcloth just very light rub the eyelashes what I like to do with the eyes closed with the eyes closed and and don't scrunch them closed too tight because you're actually burying the eyelashes when you do the the roots of the eyelashes when you really scrunch close so just gently close your eyes just you know real gentle closure and then just lightly scrub it shouldn't be abrasive you're not trying to exfoliate the eyelids or eyelashes in any way just lightly rub with that kind of dilute No More Tears baby shampoo and that can really help people with eye Comfort if you feel like you got something in your eye your ideal eyewash is actually going to be a sterile saline solution a saltwater solution that you know they sell little bottles over the- counter uh eyewash Solutions like that a lot of people wear contacts will have that kind of eyewash solution just a sterile saline eyewash just pure salt water doesn't have to have any other chemicals or preservatives in it you can of course use not actual uh sea water salt water not salt water thank you yeah not salt water out of your salt pool not salt water out of the ocean but like a saline salt waterer that's available in a sterile now you can also just use artificial teardrops and some of those come in nonpreserved some of those come in preserved versions those are all also completely safe in the to use in the eye and there you can you know you can sort of Spritz into your eye you know hold the lid open and give it a little Spritz if you feel like you got something in your eye piece of dirt or A Lash that's not coming out just to rinse it but but having like a regular routine you know you're not going to hurt anything with the occasional eye rubbing we all do these things just kind of as a you know even a nervous habit or just absentmindedly you know you might you know scratch your arm or rub your eyes or things like that that's fine you're not going to hurt anything uh there are conditions where people sort of develop kind of a almost like a psychological habit there are certain conditions where people actually do too much eye rubbing it can be Danger ous if you're in that group but for the regular run-of-the-mill every day occasional eye rubbing fine if you certainly if you get a lash in there and you're trying to rub it and blink it and tear it out uh and again in that situation you can use some artificial tears wedding drops saline drops uh those would be the way to do it what an incredible tissue the way you describe it you know the self-cleaning and yet so delicate a piece of the brain literally lining the back of each of our eyes like like a pie crust I mean it's a really remarkable um biological system of course I don't have to tell you that it's just it it never ceases to to amaze me let's talk about eye exams in adults so people are aware presumably that they're optometrists and opthalmologists I think it's important that we Define their different and also overlapping roles and for those that you know are past High School age probably not getting eye exams unless they're sensing a problem um perhaps not even with blurry vision or or difficulty seeing at a distance but sometimes just what feels like fatigue of the eyes or a hard time maintaining alignment of the eyes um so how often do you recommend people get eye exams what is a true regular eye exam and is it important that people go to an opthalmologist or will an optometrist suffice typically optometrists are a little bit easier for most people to access because there's usually one someplace near an eyeglass store um so what are their roles how often should we get our eyes checked yeah um optometrist and opthalmologists do have very overlapping roles in being ey care providers uh there are something over 40 or 50,000 optometrists in the United States there's somewhere around 20,000 opthamologists in the United States optometrists get an optometry degree they often have OD after their name opthalmologists usually went you know went to medical school they either have an MD after their name or they kind of a do version of a medical degree and uh and then optometrists will have done additional clinical training in that area in their area uh of ey care provision opthalmologist MD doctor opthalmologist uh Eye Care providers in addition to that training will have done surgical training in Opthalmology um now uh there's a lot of overlap and um in both scenarios uh you can be getting your sort of General exam taken care of maybe a screening exam I think that there's been a traditional differentiation between optometrist and opthalmologists with optometrist providing a little more of the primary care eye screening maybe managing early disease common diseases as well uh with more advanced disease often sort of upgrading to perhaps specialist opthalmologists in those areas but that distinction has been uh declining over time it's still true that in I think most if not all states only the MD opthalmologists uh surgeons can do eye surgeries but um both both groups of eye care providers can diagnose both can prescribe uh appropriate eye drop treatments including prescription ey drop treatments for for many of our diseases uh eye diseases and um and in some states optometrists have successfully lobbied for uh sort of expanded rights of providing Air Care Eye Care and again um access to care for you know the regular person wherever they may live is is the most important element and so being able to access ey care whether it's with an optometrist in your community or an opthalmologist that may be in your community or maybe at a distance I think that's that's the the really important thing is to access care now kind of like we were talking about with kids uh if you're in your teens 20s maybe even 30s and not having any problem you've got no complaints you can see it distance you can see it near um you know so you can read without glasses you can drive without glasses um you're not having any eye pains you know pains around the eyes you know redness of the eyes you may never present to an eye care provider uh through the first four Decades of life and almost all the time it's going to be okay right if you're not symptomatic the chance you've got some terrible lurking disease in there is low but we do wish that we had a little more screening going on because there are some diseases gloma for example my specialty the two main risk factors for glaucoma are increasing ing age and it usually presents you know in most cases actually after age 40 but also increasing eye pressure and if your eye pressure is too high you can't feel that that won't feel funny to you if it sort of slowly is crept up over the years and so from a screening perspective it is good to get some kind of screening exam could be at a public health fair could be that you go into the local optometrist just say hey I've never been checked I'd like to be checked once make sure everything's good could you ask for sorry to interrupt but could somebody say I'd like my pressures checked as I recall at the optometrist they're going to do a puff test so they're going to blast some air um get a sense of how how rigid or or um soft again using a non-clinical non-technical language here the eyeball happens to be um now right now by the way I'm sure there are um several hundreds of thousands of people who are with eyes closed touching the sides of their eyeballs and I'm only half joking please don't do this folks um given the conversation we just had about eye cleanliness and eye rubbing but my understanding is is that the old F truly old-fashioned eye pressure exam was you would close your eyes and the opthalmologist would gently press to see whether or not your eyes were more rigid than last time yeah is that right yeah that's called botman and you can kind of you can you can kind of just take one second if you're listening and press on your eyes just very lightly and you there's a little give of course the eyelids part of that give but but it's not it's not like rock hard and if we press and it feels under the eyelid like gosh something under there is Rock card then we know something is wrong that is way too high pressure if it's rock hard but I'll tell you our ability to differentiate the fine points of eye pressure other than Rock Hard or not rock hard is pretty limited so yeah the optometrist office or the opthalmologist office as part of a comprehensive screening exam they'll check the eye pressure they'll look at the surface of your eyes make sure everything's looking healthy there including the eyelids and lashes and the look inside the eye and be able to scre green for these diseases that way too in addition to checking if you're complaining of any you know blurriness at distance or at near now after age 40 or so a lot of people will present to an eye care provider because we all get what's called presbyopia and presbyopia just translates to disease vision of the Aged so you know myopia is our word for nearsighted hyperopia is farsighted actually emat means normal sided so I can see at distance without any glasses I'm emat Tropic but then we all get presbyopia and as we age the lens inside our eye that's helping focus light onto our retina gets stiffer such that our eye muscles are no longer able to relax and reshape that lens and we're not as good as we age at moving our Focus from distance Vision distance Vision by the way is basically anything 3T or further away You're basically viewing light rays coming from Infinity at once you're past three feet so three feet or further being able to focus that into 14 in or 12 Ines which might be a normal comfortable reading space for you we lose that ability to flex our lens relax our lens uh refocus our lens from distance to near and most people around age 40 could be a couple years years before could be five or 10 years later that you notice it but sort of around that time you start needing reading glasses you need a little extra even if you can see fine at distance and don't need prescription glasses for distance you need a booster you need reading glasses for near I don't know if you're experiencing this yet yeah I'm really intrigued by this but maybe you could clarify when you say reading glasses do you mean just a magnifier because I use a you know a 0.5 or a 75 magnifier for reading but I try and rely on them as little as possible and I want to get to this about using glasses as a crutch and the problems with that um I have a story about that too I seem you know it's no coincidence I decide to work on Vision I mean after all um had a bunch of vision issues that fortunately are corrected but you know I I do experience for instance when I wake up in the morning if I look at my phone which by the way folks I try and get outside and see sunlight first before ever looking at the phone but I'll notice when I first look at my phone in the morning that I can see it very clearly through my right eye but that if I cover my right eye my left eye is extremely blurry to the point where I'm like I'm calling Jeff you know I'm I'm afraid but then over the course of maybe 10 15 minutes it resolves and I don't think it's because something's in my eye I don't think it's pressure of having slept on that side I don't think it's a lubrication of the eye issue um but the two eyes seem to come into Focus so to speak um at different rates early in the day and if I pop my readers on I can see right away so I will use readers late in the day often um if I want to read at night or something that sort it just it feels so much more relaxing I feel like like I can finally relax whereas otherwise I realize that I'm straining in order to see does is there any um clinical clinical data in what I just described yeah I you know Andy I'll tell you my story that's like that and um we were living down in San Diego when you and I were both professors at UC San Diego and uh we had moved into a house and I found a pair of glasses a pair of reading glasses uh in a closet and you know we asked around you know did any of the grandparents uh leave some glasses behind nobody seemed to know who they were so we we finally just decided like well I guess the people who moved out of the house just left a pair of glasses you know in this in the back of this closet and then I tried the glasses on and I looked at my phone up close and was just like oh my God wait a second I didn't realize how blurry my near Vision was and this is back I was about 40 42 something like that so so I didn't even realize until I put on the readers and these were you know 1.25 magnifiers you know so also mild mild ones and I'll tell you I got addicted because who doesn't like good Vision right right right I mean oh my God now I can make the type smaller on my phone I can you know was wonderful and you can relax a bit I mean the musculature that's responsible for for moving the lens and focusing the eye and then all this extraocular musculature I we forget I mean I'm definitely going crows feet um around my eyes uh probably because I you know squint or something but you know just the ability to relax one's face it's just feels like you know more more energy I feel like can be devoted to what we're actually looking at not making light of this yeah well pretty soon I just kept that one pair of glasses with me all the time and I would just keep them in a pocket and whip them out whenever I was you know working at near using my phone at a little greater distance like a typical computer distance I could still see the computer fine so it really started for like kind of that close-up phone it was it was I could get into here but not all the way into here and um yeah and then pretty soon I was just totally addicted and so you know then I had to go buy 10 pairs and leave them one by the bedside table you know one in the car one in the computer bag one on every desk I work at yeah because I'd leave them anywhere and forget them and that way just yeah exactly you know yeah so um yeah so whether using the readers accelerates the progression of dependence on the readers is still uh not you know that's still up for debate you know some studies say maybe yes some studies say maybe no but certainly psychologically we get addicted to good easy vision and if you don't have to squint and if you're not straining your muscles and all of a sudden the the text on your phone looks crisper again uh boy that's addictive you're you're going to like good vision and so it feels like you're getting dependent and how much of that is change in the eye muscles and how much of that is just the pschology of wanting to have good Vision I think probably the jury's a little bit out on that point but point being your either either way your dependence will grow and as you continue to age 40s 50s up until about 60 65 the ability to shape that lens gets weaker and weaker and weaker and so you need to move from the 05s to the 1.0s to the 1.5s and the coke bottle to the coke botle thankfully you eventually max out at about plus 2.5 or plus three because that's the amount of extra refractive power that you need in magnifiers to take the equivalent of your Infinity viewing and bring it up to 14 in to read it near basically you need a plus three and then you don't need any lens ey muscle action whatsoever so you kind of max out around 2.5S or three so because most people will hit this somewhere in their 40s this sort of like gosh I'm having trouble on the phone I think most people actually use that that's like kind of the first time for a lot of people they're like well I guess I should go to the eye office right see the optometrist or maybe opthalmologist and when they go in they should be getting the standard in either of those offices will be to give you a full screening exam including maybe it's the puff test or a blue light test or a little pen that that can check your eye pressure and having a look inside and seeing if you're retin and optic nerve look healthy it's kind of screening for all the main diseases and so and they'll tell you at that point hey you look great if you feel like your glasses aren't doing it for you in a year or three years come back or they might say hey I've detected something I'm worried about you and they'll set up a routine for your ongoing Eye Care assuming that somebody doesn't have um you know some form of amopa or the need for some really robust corrective lenses and they are already using readers let's say a plus one or so you know plus one plus or minus point5 reader would you recommend based on my experience and based on your experience that people strive to avoid using them for as long as they can because in some sense if that's the recommendation then the recommendation is that people kind of deal with the fact that they're seeing a little less well or a lot less well than they possibly could so I'm assuming that people can still drive well people can still read but it involves a little bit more effort in other words are we weakening Our Eyes by using these these readers I I realize you said that the data are a little bit mixed but as long as one can perform their required daily activities would we be better off delaying the use of readers there's two important answers to that question one is regarding the lens and the eye muscles that control the lens and it's entirely plausible that's what I was saying kind of the data is mixed on but it's plausible that if we would just exercise like work a little harder kind of not use as strong a reader as we want or not use that reader as often as we might really enjoy uh are we exercising those muscles and kind of exercising the ability to to to stretch versus relax the lens and kind of slow the progression from the 1.0 reader to the 1.25 reader to the 1.5 reader Etc right and so that that's why I saying the data is mixed but there's a good premise that maybe if you're exercising but let me give you the on on the other hand it's probably ideal to give your retina and your brain the sharpest visual signals you can so why hamstring your retina and your brain and your vision and your enjoyment and ability to read or do near work by constantly undercutting the the the reading glasses or leaving them out or you're not helping the whole back part of your maybe you're maybe you're helping the lens but you're definitely not helping your retina and brain by feeding it blurry information all of that time so I actually think just give in use the readers have your enjoy your Best Vision all the time and if that means wearing glasses and by the way if that means that you're going to have minus two glasses for vision and you'll eventually need minus 250s for distance Vision or if you're going to need readers 1.5 readers now and in a few years 2.0 readers okay so you'll get the next reader it's it's actually not a big deal you can you can you know you're not you're not hurting you're probably helping and in the meantime it's an enormous enjoyment to actually have good Vision all the time right so so I actually counsel people just wear the glasses that work best for you you know you're only minimally changing how your prescription is going to change over time very minimally so just enjoy your Best Vision even if it's using readers for close or or prescription glasses for far appreciate that recommendation I do enjoy you using the readers at night it really helps for all the reasons I mentioned before I've noticed that driving at night presents an enormous strain on my visual system and I've noticed this for a number of years are there any um I know there's something called stationary night blindness I don't think I'm stationary night blind um I think the mutation for stationary night blindness was identified in the Kusa horse or something like that these were horses that you could walk up to very easily and they wouldn't even you until you're right there someone's going to correct me on this it's the internet but I think that the mutation was identified um Etc but I don't think I'm stationary night blind but I do find that driving at night I get very fatigued and then I'll sometimes even wear my plus one readers when I drive at night which removes the fatigue even though I'm looking more or less at a distance are there some conditions that make it hard for people to see at night for which they would want corrective lenses um and what what sorts of biology underlies that assuming that somebody is not stationary night blind or a Kusa I think is the name of the breed horse yeah that's a great question you know we for the for the optical defects in our eyes most or many of which can be corrected with just having the right prescription lenses we can get away with it without using those Corrections in brighter light and so during the daytime um you know uh you could be slightly blurry you know if I have a real bright light uh and a good high contrast book you know with black letters on the white page I can get away with reading that without my readers unlike if if I'm in dim light then I feel and that might be kind of what you're describing if you're reading at night you actually prefer to use the readers a little more even at night because we can make up for a lot of that blur if we just have bright enough signal and contrast coming into our eyes makes sense yeah so when you're driving at night and noticing this this might be revealing a little bit of a need for glasses now I'm not suggesting this is the answer but far more common than having congenital stationary night blindness would be being what's called a latent hyperope okay now we talked about already how the lens inside our eye goes from focusing at distance to then we squeeze the muscles the lens actually rounds up and allows us to focus it near some people's Optical system of their eye is actually wired uh or designed or sort of set up in length not for regular distance which would be anywhere from about 3 feet to Infinity but it's actually designed it's actually tuned for being beyond Infinity which doesn't make any actual sense when you talk about it but just the Optics of the eye at their best Focus are actually focusing the light behind the retina and and if you're doing that when you're younger you're actually using some of your focusing power to to to use those muscles strain those muscles relax that lens round up that lens and have your vision Focus From Beyond Infinity to normal distance like distance vision and so if you're a late and hyperope you are constantly using those muscles and again if you're tired it's the end of the day your muscles are feeling a little fatigued uh your latent hyperopia or by the way if you've had a drinker too uh alcohol can do this too your latent hyperopia can kind of kick in especially as we're aged and we're not as good at refocusing that lens anyway and now all of a sudden your vision is kind of reverting to its natural state which is slightly out of focus at distance because it's actually focused Beyond infin if you will and so all of a sudden you put on that plus one just for a little extra booster kick and you're like oh yeah yeah distance vision is clean and easy now so I'll have to bring you into the clinic to really be sure but you could be exhibiting a little bit of that kind of lat and hyperopia I definitely want the ey exam and I want it from you and I've been called a lot of things in life um and we can now let add perhaps latent hyper op uh to that I I'd like to take a quick break and thank our sponsor insid tracker insid tracker is a personalized nutrition platform that analyzes data from your blood and DNA to help you better understand your body and help you reach your health goals I've long been a believer in getting regular blood work done for the simple reason that many of the factors that impact your immediate and long-term Health can only be assessed with a quality blood test the problem with a lot of blood and DNA tests out there however is that they'll give you information about certain lipid markers or hormone markers but no information about what to do with all of that data inside tracker makes it very easy to look at your levels of hormones metabolic factors lipids Etc and then to assess what sorts of Behavioral nutritional supplementation or perhaps other interventions you might want to use to bring those numbers into the ranges that are appropriate and indeed optimal for you if you'd like to try insid tracker you can visit insid tracker.com huberman and get 20% off any of insid trackers plans that's insidetracker tocom huberman to get 20% off another piece here and again this discussion is not designed to be an eye exam for me but um I have yet another experience that I think illustrates the key importance of both critical period plasticity and the questions about whether or not to rely on corrective lenses and that is uh from the time I was pretty young I could make my sister laugh by deviating one eye inward so not crossing my eyes but moving one eye Inward and then what happened was when I was in college and studying a lot a lot and getting very fatigued I noticed that this I started just kind of drift in a little bit so I went to the campus Health Center and they gave me a prescription for a prism lens which of course redirects the image but then I noticed that this eyeball moving Inward and I guess for those of you watching on uh on YouTube and not just listening um I can do this um by just moving one eye in all right as I can move this eye in yeah it's fairly pronounced it started to really drift in at at a relaxation State and I started seeing double again so I thought these prism this one prism lens lens is a crutch of the sort that I really don't want crushed the glasses broke them and and never went back to them um I have voluntary control over it but that's one example where the corrective lens can actually create a pretty significant shift in eye position if one relies on it so this gets back to this issue of um when should people Force themselves to work with their natural vision maybe do some more far viewing um as a and certainly get outside and get sunlight into the sunlight full spectrum light as opposed to relying on corrective lenses yeah and and you've raised a very important distinction here and that's the distinction between the muscles that are inside our eye that we use to relax and refocus the lens and the muscles that are on the outside of the eyeball of course inside our orbit but on the outside of the eyeball that turn the eyes and if everything's working right keeps our eyes really yolked straight and we talk talked about earlier uh this possibility that you may have been having a little bit of intermittent esotropia or intermittent turning in of the eyes that then culminated on that day day at the pool when you really noticed it um and your ongoing ability to actually turn one eye in could be related to that I I remember as a kid standing in front of the mirror and I I couldn't get my eyes to cross even though friends could do it and you know so you know I I I I was in the losing group on that on that end of the SP became an opthalmologist and then I became an opthalmologist which and I must say it is very reassuring that you have excellent Vision you know I always worry when I go to a new dentist and then I look up at them in one moment and if they're not wearing a mask that their teeth are not you know pristine I think well what am I doing here so you know an opthalmologist with excellent Vision G brings me uh great comfort the cobbler's children should have shoes right exactly um but yeah so so when to correct when not to correct with lenses and I realize here we haven't talked at all about contacts we've been talking about eyeglasses yeah let's come to context in a sec if you want but yeah let let let me return to your question the difference between providing corrective lenses that allow you to focus for near or distance uh in your glasses so that you can go easy on the inside the eye eye muscle having to work so hard a lot of people get eye strain and sort of uh headaches even from that from not having an adequate correction that they're wearing that's different actually ESP especially when we're children or again into that maybe even into the teens and even young adult years from the eye muscles on the outside of the eyes which are supposed to be yoking our eyes straight and so that you have them both looking at the same point in space and and there it's actually quite a common treatment to try to undercorrect and ask people to exercise and not just give a prism that says hey if your eyes in sometime we'll use a prism so the light sort of looks right to you but rather undercorrect that and sort of really force you to exercise trying to yoke your two eyes straight together and so that's that's in contrast and there actually I I think many optometrists who often specialize in in what are the right glasses to give in a situation like that uh wherever possible especially during uh development as our bodies are developing as we're sort of growing in our younger years uh take the approach of intentionally trying to undercorrect not use a prism or not use a full prism correction uh and um to to really help uh sometimes it's also like an accommodative reflex that your eyes are just you're spending so much time reading it near when you read it near your eyes actually naturally turn in a little bit to focus uh at that near so that they can be looking at the same word on the page uh and that can also if you've got kind of too much muscle drive you can overshoot that and so sometimes just using not a prism but like a little bit of a plus lens in kids just so they don't have to work quite so hard to turn their eyes in and sort of EX ovx exercise those muscles these are all great examples where going to an iare provider often for these kinds of issues an optometrist is the right first place to start you'd like to say that every optometrist and every opthalmologist is always going to give the exact right thing for for each kid or young adult or older adult to do and and we wish all medical care providers were were always right on Target and a lot of times it's a perfect science but a lot of times it's an imperfect science and so it could be that at least with you know we're now 20 25 30 years later but like it could be that today that 20 year-old version of yourself would have been given a different uh approach to having one eye intermittently occasionally turning in like that is there any real value to um near exercises you know so-called pencil push-ups or uh smooth Pursuit tracking I've talked a little bit about it before on the podcast but that was you know some time ago so what are your thoughts on on that is there any value whatsoever I mean they they require a little bit of work just like going to the gym but you know you know 25 reps a day of near far um especially as one is transitioning from age 30 to age 50 um is it worthwhile yeah is it harmful in any way definitely not harmful and again uh you know would it slow down or sort of um slow down your progression to Presby opio or needing those reading glasses uh could be some people also develop um sort of uh you know a real failure to properly turn their eyes in and so they actually would benefit if you've been diagnosed with that inability you're having double vision at near but not at distance um so that kind of convergence insufficiency for example uh that then pencil push-ups often get prescribed as a way to try to exercise those skills in you know uh in your eye muscles um I should interrupt here and just tell people for those of you that are listening not watching the pencil push-up we can put a a link to it uh in the show note captions but it's essentially taking a pen or pencil looking at it at um at Arms distance and then uh slowly moving it toward your nose and U deliberately working hard and it is a bit of effort to continue to focus on it at a close distance at some point it will become blurry because I can't cross my eyes any further um unless I become a cyclops and then moving it back out again and doing that for you know 10 to 25 repetitions maybe once or twice a day a few times a week um that's what those are pencil push-ups yeah yeah so um you're certainly not going to hurt anything there are other situations where those really do get prescribed and there's definitely some good clinical trial data suggesting that they can actually help for example recovery from concussion a l a lot of people actually one of the really telling ways to diagnose concussion and this can be concussion from sports or a fall or you know any any source of concussion uh your smooth Pursuit which is the ability let's say I've got a DOT moving around in a circle on a screen and I'm following that dot with my eyes my eyes should be able to very smoothly follow that circle around the lit up hockey puck on one watching a hockey game is that like that you're a hockey fan right like that you know just following a ball you know following any movement with smooth Pursuits of your eyes and after concussion that actually those systems in our brain the sort of reflexive ability to properly follow that use that visual input to tell your ey muscles exactly where to move gets disrupted and so all of a sudden your smooth Pursuit starts to look choppy it's not so smooth anymore and it's actually a way to diagnose and follow recovery from concussion and part of the visual rehab sort of neuro rehab one of the approaches being used and further studied still in recovery from concussion is actually doing those kinds of exercises like pencil push-ups or basically what you've described as focusing from far away to focusing near and doing that back and forth and using that to sort of like help regain uh the tighter control of our eye movements and that eye brain connection so if traumatic brain injury causes deficits in smooth Pursuit eye movements and some of the recovery protocols for traumatic brain injury are to have people do smooth Pursuit protocols and pencil push-ups are these also the sorts of things that anyone can just do I mean whenever possible we like to share tools for various aspects of Health on this podcast but of course we don't want people cowboying this stuff in a way that could be detrimental to their to their Vision so is it okay to get on YouTube and find a smooth suit um uh Tool uh we can put a link to these there there are several of them um and people spend a few minutes doing this yeah you're definitely not going to hurt anything so totally fine to do it and some people may notice you know like they feel a little more visually active if they do these kinds of exercises um I think most people would do them and not notice something in their daily life we actually have um made so much progress you know in research in thinking about how do we take the diseased or dysfunctioning or aging eye and get it back to healthy and normal but there's a whole other area of science that's we're really just barely touching we've actually we've actually just opened a vision performance center to really get at not just how do we rehab the sick eye back to to health but what's the difference between functioning normally and functioning above normally for example athletes when they get studied for visual Vision characteristics they have faster visual reflexes higher visual Acuity uh how much of that was you know genetic how much of that is trained we don't really understand could we train all of us with you know normal vision to get up to Supra normal vision these are like great important questions that are really relevant to you know every regular person of course you know people doing Esports in The Gaming Community and athletes this part of what we're studying in the vision performance center but these are really really big opportunities to try to understand how do we move people from normal vision to supernormal vision and there's evidence that you can do it so here here's a great example some athletes train using these special goggles that actually use electrical signals in the glasses part of the goggles to actually black out your vision 130th of every second 2 30ths of every second 3 30ths of Every second now imagine you and I are passing a basketball back and forth except you're wearing goggles and all of a sudden you're only getting 90% of the data of where's that basketball on its way to my hands now you're only getting 80% now you're only getting 70% of that visual information and you are practicing right you are getting good at catching a basketball when you only have a fraction of the visual information and now I put you back on the basketball court without the goggles you might be really good at passing that basketball around and catching that basketball right and so the idea that we could train and understand the biology of training to get the eyes from normal to Super normal performance I think it's an amazing area and one that we've really just started to dig into that's fantastic so this is a a new program at Stanford through the department of Opthalmology is it linked up at all with the WOAI performance Institute yeah actually there's been a lot of focus over the years I think in human performance and there's actually a new human performance uh Alliance and Center we've we've we've long had really run through the department of Orthopedics a human perform laboratory that's really you know much more about joints and muscles and strength and conditioning and stretching uh to layer onto that now a real understanding of how vision is operating you know it's interesting let's go back to the example of concussion you know we've got I don't know about 800 Varsity student athletes in all the different sports at Stanford and you might have a student athlete come in and say you know something doesn't feel right I got a little hit on the head head I feel like my vision is a little bit messed up maybe I've got a mild concussion you could imagine doing some of these tests on some of these performance athletes for example and saying well gosh you you look normal but actually they used to be operating at a supern normal rate and this is a noticeable decrement for them and so just starting to study and understand what's the difference between normal and supernormal how do we go back and forth between those two how do we measure that difference and maybe ultimately how do we train into that difference I think it's going to be exciting and not just for athletes you know for for regular people you know you talk about driving at night is there a solution where we could train our eyes to be better at driving at night and I don't know maybe reduce the number of accidents that happen out in the world so well certainly there's um physical training protocols which are redefining what a 60-year-old or a 70-year-old could look like and feel like and be able to perform like why not do the same for vision um so I don't think there's anything um Supernatural or greedy about doing it I think that's the excitement of biology and neuroplasticity that you can extend it forward as opposed to just trying to wire up correctly during development this is a perfect time for me to ask you a question that I'd love a clear answer on if it's possible it's not always possible which is could you define 2020 vision and a few of the variants so so that any person could understand it so we think of 2020 as perfect vision what does that mean what would degraded Vision look like whatever those numbers are and then what would above normal super normal vision look like and is it true that fighter pilots have supranormal Vision yeah that's another population like like like many athletes of of people who may have sort of better than normal vision 2020 you know we Define almost everything we do based on you know kind of a average not sick human being adult whatever it is right and so 2020 Vision means that you can read the smallest letters at 20 feet away that the average healthy person can read at 20 feet away so you can read at 20 what they can read at 20 okay now if you have worse than 2020 Vision maybe you have 2025 Vision 2040 Vision maybe you have 2200 Vision which on the ey chart at the office is like the Big E at the very top is 2200 Vision that means you can read at 20 feet what a normal person could read at 200 feet right so you've got pretty limited lower Vision we can measure down to like 2400 28 800 at that point we're getting into like gosh can you count how many fingers I'm holding up you know that kind of thing and then ultimately hand motion can you even tell if my hand is moving in this side of your vision or this side of your vision and then ultimately after that light perception can you tell if the room lights are on or off right and that's kind of the edge of of being actually fully blind we call Legal blindness in the United States typically 2200 or worse and is it true that there are people who are legally blind that are out there driving as we're having this conversation I I have to imagine that that is unfortunately the case but it shouldn't be because those people obviously are really severely impaired and and and and that's obviously quite dangerous so so so that's 2020 now it gets worse 2040 2080 20000 can it get better yeah it turns out that people can be sort of on the other end of that curve and so we could have athletes and fighter pilots or people who have had lasic surgery who are 2015 2010 if you're 2010 that means you can see at 20 feet what the average person needs to be only 10 feet away to see right and so you've got better than normal vision and people do get to that through a variety of ways and so it is possible to have better than 2020 Vision does the degree of visual Acuity because that's really what we're talking about here differ dramatically between the two odd and most healthy people no um you know remember we talked about you're born with something like 2200 Vision takes you a couple of years and it could be a little bit asymmetric 2200 Vision yeah that reminds me um I've seen images of what babies can see you know parents love looking at their child and thinking that their child is looking right back at them and indeed often the child is looking right back at them and your face to your child sorry to break this to you folks is incredibly blurry even at that close distance for probably the first 6 to eight months even before you come into sharp relief they're not seeing the fine details of your face yeah so smile big that's right smile big keep those eyebrows dark right and keep cooing at them because they can hear pretty well early yeah the Optics of newborn babies are just dreadfully bad but they need visual stimulation now other species na you know Hawks uh Raptors owls that hunt uh they can naturally have 2010 28 Vision right so much better vision and that's just their normal vision as best as has been measured so so there's definitely the potential for us to have better than 2020 Vision now all of this we call Visual Acuity and just to be clear for everyone that's the vision in the very center of your vision like when you're reading or looking that's the very center of your vision our vision is actually actually described variably as a hill of vision the peak is in the center that's let's say 2020 in most people right but it's it's normal to have that slope off and our visual Acuity your ability to read the eye chart on the edges of your vision if you can read the Big E that's pretty normal like you would be 2200 out on the edges of your vision and we would feel like yep that's pretty normal um so so our highest Acuity Visions in the center and that's a big part of why we spent a lot of time using those eye muscles to look around right we got to we got to get a little bit of a high Acuity view of what's around us uh fill in fill in the gaps of what our what our brain is is interpreting our peripheral world to look like it's almost like we have two visual systems we have a high Acuity High pixel density camera in the middle and then surrounding that is a pretty low resolution but very fast detector camera yes yeah yeah you mentioned lasic but I want to make sure that before we talk about lasic that we talk a little bit about contact lenses is there any detriment to having a piece of glass or a piece of plastic on the front of your eye all the time and the reason I ask is not because I think we should live necessarily exactly like our ancestors but it's a pretty bizarre adaptation to put a lens directly onto the front of the eye you have to imagine that the cells and tissues there are accustomed to getting a certain amount of oxygen they're accustomed to getting a certain amount of interaction with the environment and and you also now adding another surface the way that the tears are going to interact with the um you know with the corny of the eye are probably changed and who knows maybe it doesn't make any negative difference at all but you know putting a contact lens on the front of the eye is you know about as close to putting a device on your brain as I can think of except for maybe the clear uh implant yeah yeah that's a great question now first of all um I want to distinguish uh there are few really medical uses for different kinds of contact lenses like scleral contact lenses for people have certain diseases there are other kinds but I think what we really want to talk about right now is just kind of the run-ofthe-mill I want to get my prescription taken care of but instead of wearing glasses I'm going to wear contacts contacts even the newest generation contacts yes they sort of uh change the tiar Dynamics on the surface of your ey they um uh they decrease the oxygen you know diffusion that's just sort of out in the air onto the surface of our eye onto the cells that are on the surface of our eye but most of us especially as we're younger have enough tier film Reserve enough oxygen Reserve that we can easily tolerate these polymer gel soft contact lenses and and wear them happily the advantage of contact lenses over glasses purely from the perspective of correcting your vision is that there's different elements of of of of the shape of your eye that need to be corrected if you need corrective lenses and so for example if your the basketball shape of your eye is a little too steep or a little too shallow that's what the standard glasses correct uh you may have been told that you have something called a stigmatism that's where instead of having a basketball shaped eye you have a slightly football-shaped eye it's not round in the same dimensions on both axes and again glasses can correct that but then there's higher order aberration in our corneas in the clear window in the front of our eyes or or to some degree in the lens inside the eye that are that are focusing the light that the glasses prescription can't correct but if you have nice smooth contact lens on the front it can correct so a lot of people who wear glasses and contacts will report that they have a much higher quality of vision with their contact lens correction than with their glasses correction and again in service of enjoying the best Vision that you can enjoy in your daily life that's an upside to seeing if contact could work for you now there's another element though and that's like gosh is there a risk of contact lenses and especially as we age um we have less tear film Reserve so contacts may become less tolerable as we age and the other thing is being really good about the cleaning because you know the contacts can trap bacteria or fungus and if you get a corial infection from a contact lens it actually can be quite devastating to your cornea even if you successfully treat the infection you can be left with some corneal scarring thankfully this happens very rarely but when it does happen it can be quite difficult on you know on the person thereafter to sort of suffer through having maybe a scar from that infection on the surface of their cornea that they that leads to some blurring vision for example so we always recommend that if you're going to wear contacts that you be really attentive to whether you're tolerating them well and then also to be really attentive to the recommended use and cleaning of the contact lenses I actually recommend that even though they're a little more expensive to afford that people should almost always be just using the daily contact lenses that they don't have to clean or use for uh you know two weeks or four- week period so these are disposable contact lens disposable and I hate to think of you know I don't know filling our oceans or what have you with more more more polymer plastic but at least the contact lenses are small and it's much safer for your eye to use a daily disposable than to use a two we or a 4 we and be responsible for the cleaning the other thing to be really responsible about is sleeping in them overnight because overnight when your eyelids are closed of course now you're getting even less oxygen to the surface of your eye and actually most bacteria especially many of the Infectious bacteria to our bodies and to the surface of our eye are actually bacteria that don't really like oxygen and so we've got a low risk of getting bacterial infections on the surface of our eye but if we use contacts too much don't clean them or sleep in them overnight when our eyelids are closed and now there's even less oxygen kind of helping keep the surface more more clean if you will uh that increases the risk a lot so being really good with the recommended use and cleaning of the contacts is critical considering daily use contacts you don't have to and look most contacts are going to be the two we or four-week kind where you put them in the cleaning solution overnight each time give them a good rinse and put them back in the next say and again most people 99.99 some perent of people are going to do just fine with that follow the instructions and never get into trouble as we age they're going to become less tolerable people are going to say I used to wear my contacts for 12 hours now my eyes feel really dry after six or eight or 10 hours maybe some years after that they say gosh I could barely use it for four hours I only use them when I go out on a Saturday night uh and and that's okay you can you can you can back off as you need to back off but in the meantime if it helps you especially in the younger decades if it helps you really enjoy uh Your Best Vision great what about UV protection in eyeglass lenses Andor contacts um I've dealt with many questions about blue light I am not somebody who believes that all blue light is terrible I think it's important to avoid Bright Lights of any wavelength late at night if you want your melatonin produ to be normal and you want to sleep well doesn't matter if you're wearing blue blockers or not if you're just under blasting Bright Lights it's going to suppress your melatonin and yet some people enjoy blue blockers for that reason nowadays A lot of people wear blue blocker glasses or blue blocking lenses or conts throughout the entire day thinking that blue light is bad for our eyes during the day I happen to subscribe to the idea that we want as much bright light as we safely can tolerate during the day ideally from sunlight in order to set our circadian rhythm and yet a lot of eyeglasses and a lot of contact lenses out there have UV a Andor UVB blocking features to them so what are your thoughts on this and I'm perfectly happy to be wrong and revise my my stance on this um yeah what what what do you think about this UV AB blocking yeah it's a good it's it's a it's really important to distinguish that UV light on the light spectrum is right next to blue light red lights on the other end and of course infrared is beyond that and our eyes other animals can see these but our eyes can't see infrared that's why we call it Beyond red and we can't see ultraviolet as we call it Beyond Violet UV light is right next to Blue Light UV light is known to have a lot of adverse effects it's not really good for our skin and therefore you know we really want to avoid Sunburn and kind of UV D you know exposure and damage on our skin similarly it's not really good on our eyes and it affects both the ocular surface a little bit in terms of like kind of how dry or irritable your eyes might feel for some people and certainly over the long term UV light will accelerate the formation of cataract which is a blurring of an oxidative blurring of the lens inside the eye profound UV light can be damaging to the retina if you're getting way too much on the inside um so uh so blocking UV light I believe is just absolutely standard in every pair of eyeglasses and uh I don't know actually how much to what degree the different kinds of contact lenses also filter at least UV light now blue blockers blue blocking glasses is totally different and as I say like I think almost all glasses because the Plastics almost all glasses are not made of glass anymore they're made of plastics uh but I think almost all of them now filter the UV light which again is like probably the safe move for our eyes and periocular environment around the eye environment um so uh blue blockers you know that's been a huge fat and I'll tell you the last three years through the pandemic everybody getting on their computer hours in front of Zoom meetings where we used to walk from building to building for a meeting things like that um I you know I I remember you know like the sort of big uptic in these kinds of questions and I'm not sure that there's any that blocking blue is helpful in any way and as you say it may actually play into sort of circadian entrainment of our natural daily Rhythm so so I think blocking UV is a good idea and I think it's pretty standard um you know they make glasses by the way that actually react to UV light they're called transitions there maybe a few different brands I don't know uh but but you know these are the sunglasses that are clear except then they turn dark if you're out in the sunlight and it's not just any sunlight it's actually the UV uh wavelengths that that cause the chemical reaction in the glasses to turn from from Clear see-through to to sunglass blocked glasses and um you may notice if you if any of you out there are using these kinds of glasses uh that they don't work in the car you'll wear them in the car and they won't go to sunglasses even though it's sunny out and again that's because all standard car glass also filters UV that's why if you're riding around in the car and it's sunny out you've got your hand you know up next to the window uh wearing a t-shirt you never get a sunburn through the car window anymore because all our car glass is also filtering UV light for us so so that's a very informative answer and before we started recording you and I were discussing this practice of morning sunlight viewing which again I highly recommend over and over and you pointed out that low solar angle sunlight so sunlight Light low in the sky viewed for maybe 10 minutes a morning and again not forcing oneself to look at it and stare but blinking as needed is not going to cause extensive UV damage to the eyes it's really the when the sun is directly overhead um that we're getting a lot of UV which raises this other question which is for people that don't wear corrective lenses and therefore are not blocking UV light to the eyes um what should they do are they in trouble should they be wearing a brimmed hat brimmed Hat's a great idea that'll get rid of a lot of the direct light into the eye of course you still have reflected light off of surfaces uh and that that can include UV light of course um you know wearing sunglasses outside even if you don't have corrective lenses you know it's may may also be more comfortable to wear sunglasses outside um so so these are all fine you know at the end of the day it's probably not making a huge difference in the health of your eye whether you've spent the last 50 years wearing sunglasses really dogmatically for your out time or not um you know if you were going to develop let's just say age related cataracts inside your eyes which we'll all get cat if we all live to 120 we all get cataracts you know it's going to happen some people younger some people older maybe if you were really dogmatic about wearing your UV blocking sunglasses maybe you'd get your your cataracts at 75 years old instead of 72 years old it may not be a huge difference in that regard um so again not something to be super stressed I think it's I think it's more a question of just what are you comfortable in uh and then certainly I will say the the other advantage of a wide brim hat is it's keeping sun off of your face and these are the you know some of the especially the upturn portions of your face like the cheeks and the nose these are the some of the most common places to get some of the skin cancers that you can get over a lifetime of sunlight exposure um so you know the wide Brin haap is is it's helping you for that as well can't help but ask about Comfort at very levels of brightness I'm the person that when sitting in a cafe or something and on a bright day I can be directly across from somebody like you who seems to be perfectly fine without sunglasses and maybe even we're shaded under an umbrella or something of that sort and I'm squinting like crazy is it normal for there to be a pretty wide variation in sensitivity to light and does this have anything to do with the lightness or darkness of the eyes you have brown eyes I have green eyes but is there any real correlation there yeah you know it's a good question I I don't know if it's been formally studied but I will tell you like I have the same impression you do which is that if you have uh a blue eyes or light colored eyes that you're more likely to have more sensitivity we know that there's differences in the iris muscles that constrict and dilate in response to light uh for example when you go into your eye care provider and they're going to do a dilated exam and they put the eye drops in your eye that dilate the eyes they sort of change the the the nerve impulses onto the iris muscle so the iris dilates and you get those big big open eyes um people with blue eyes we absolutely know blue or Hazel or light colored eyes uh you put that eye drop to dilate their eyes it's going to lasts four 6 eight hours whereas in a brown-eyed person often the dilation only lasts one two 4 hours so there's clearly biological differences between the irises and their muscles and maybe the nerve that feed those muscles uh between lyed people and and darker eyed people uh and that may also therefore relate to this differential sensitivity that some people have you know if you're not able to constrict your eyes in the bright light as effectively you're going to find that bright light more frustrating more annoying uh you know even painful people will feel like their eyes are cramping almost uh as they try to get that those eye muscles to activate to bring down down the pupil and block some of that excess light from getting in interesting yeah let's go back to lasic what is lasic and should I get lasic eye surgery does it does everyone need lasic can it help every can it make us you know super physiological you know can it make me a 2010 you know often it can I'll just say that you know right up front it is amazing people will come out of lasic surgery uh uh better than 2020 but uh the cornea weal about before that's the Clear Window on the front of your eye all the light has to get through there and we talked about before already like if your cornea is misshapen if the basketball shape of it is too uh too shallow or too steep then you're going to need glasses to see at distance and also at near if it's too football instead of basketball then it's going to be what we call a stigmatism and uh and then you can't uh you need a correction for that instead of correcting with glasses that sort of help shape the light so it can go through your slightly off shaped cornea instead of wearing contact lenses which also shape the light just as it's entering your cornea right on the surface of the eye you can just reshape the cornea and the way lasic does that there's a few different versions of lasic uh but basically the way the lasic does that is it actually ablates or uh uh gets rid of a little ring or rim of that corn tissue so that for example if you were a little shallow and you got rid of a little bit of that tissue around the edge with the laser the Las lasic you know starts with the word laser if you got rid of that edge tissue then you're sort of making it a little more basketball shaped right or if you were too steep on your cornea and you use the laser to kind of shave off a little bit of the the tip of that basketball right then you're flattening it out flattening out the cornea so it's that kind of reshaping and the technology has come so far that the lasic procedures can actually correct not just the regular aberration that we talked about but also some of these higher order aberration and there are different monikers for this kind of lasc it's all I think become fairly standard but wavefront guided where it's actually using light waves to measure with a very exact localization exactly how much and where to laser for each individual eye to make that cornea pass the light as ideally as possible now one or a few percent of patients will actually have a dry eye problem so after lck because it does interfere a little bit with those corneal nerves for example and I and I do think that if you're a person who already has dry eye hopefully if you're asking your eye surgeon about lasic hopefully you're being counseled that if you have dry eye this might not be a good idea for you just like contacts might not be a good idea for you if you already have a lot of dry eye um but for a lot of people especially a lot of younger people it's quite common I I I think the statistics suggest maybe 15 or 20% of people who would benefit from lasic you know who who would we who would otherwise be wearing glasses may get lasic at some point in their life and um you know I used to joke you know lasic it costs more money than a pair of glasses but it doesn't cost more money than 10 pair of prescription glasses over the course of a decade or two you know and so I used to joke that gosh if uh if everyone had to have laser eye surgery for their best vision and someone came along and said hey I've got an invention you don't have to have laser eye surgery anymore it rests on the ears and the bridge of your nose I call them glasses could they have sold those for a th000 $2,000 a pair I don't know maybe but you know there's kind of a cultural element of saying you know like I don't want to wear glasses you know I'd love to be able to walk around without relying on glasses or contacts of course people are very athletic or spending a lot of their time doing Athletics they may be quite irritated to have to deal with glasses or contacts people who have very severe prescriptions I mean if you wake up and you can't even really you know you're fumbling for your glasses on the bedside table because you have such a strong strong uh prescription you can't even see what it says on the alarm clock next to the bed you know these are all groups of patients who like really change their daily lives by getting out of glasses or contacts and taking advantage of lasic and in I don't know 99% of the time it's going to be like a safe comfortable outcome for the patient do they do lasic on kids um there are certain conditions uh unusual Coral conditions where procedures like Las at used but I believe uh it's ideal to not do it on children uh or even even young teenagers and the reason goes back to what we were talking about before you are much more likely to change the shape of your eye the and therefore the prescription you need and therefore what exactly the lasic would laser while you're still in those growing years and you really want to be able to say hey my eyeglasses prescription has not changed in the last two or three or five years because if you do lace sick and then your eye keeps changing shape then by the next year all of a sudden the L lasic is not doing you're backing glasses again right you can do a touch-up lasic do a little bit more but it's generally you know you're going to be a happier person if you've reached that point in your life and maybe that's maybe that's your late teens more commonly it's into the 20s where your eye has stopped changing its prescription every year you've been steady and stable for some years and now you do the lace B and it could easily last you a decade you mentioned dry eye get a lot of questions about dry eye and a few years ago I think you and I were at a meeting and someone who is very woven in with the companies that build and test drugs for different aspects of vision health said you know what the field really needs is a treatment that works for dry eye and I thought dry eye like of all things like why dry and then the more I learned about it I realized that there are millions and millions of people that really suffer from dry eye and for whom standard drops are just not working so what underlies dry eye is it some deficiency in the lacrone glands that produce tears for the eye and and I think of Tears is just kind of salty water um and I wonder if they are more than that is there an oil in there and if we know what's in tears why can't somebody just manufacture something that works as well as tears yeah you know it turns out you know we we we've got a lot of other eye diseases but by far the most common eye disease and and I've been told by far the most common eye treatment you know purchased by anyone now granted it's almost always over the counter things like artificial tears is for dry eye and uh in part that's because as we age our tier quantity goes down and our tier quality goes down and so what do those two mean we have two different major elements to tear and as you alluded to one is the saltwater P of part of the tear and those are made primarily by the lacrimal gland and there's a steady drip of those tear onto the ocular surface as well as reflexive tearing right if you get an eyelash in your eye or or you cry you're G your laal gr will actually squeeze out extra saltwater tears uh onto the surface of the eye and so so that's that's where most of the sort of wet part is coming from but there's also essential oils critical oils these come from other types of glands including glands in our eyelids called mayian glands and the oils form a surface over the saltwater part of the tier film and and also intermix into the teers and as we age we go down in the quantity of both saltwater part of our teers and oil part of our teers but also the quality and in particular the oil parts uh uh can often be seen to be going down more quickly the the ey drop industry has pretty much solved for replacing the saltwater part of your teers right you can get either bottles of preserve preservative containing you know you could use that bottle all month or for for a month or two or you can buy these strips of preservative free artificial teers which are really basically like the saltwater component and you can use those preservative free ones we have patients using them every hour if they need to right you're not going to hurt anything with preservative free artificial tears you just drop them in just drop them in yeah either ey as often as you want or need when you feel it it's exacerbated in the world we live in uh uh especially these days now with more time on computer it turns out that when you read including when we maybe used to read more books than we do now but also read on the computer or stare at the computer screen or work on the computer or actually just even watch the TV done very careful studies you blink less when you're doing any of those activities and when you blink less you're redistributing the tears less effectively and you squeezing out less of the tears including less of the oils uh as effectively as you could be when you're blinking and so um so between aging tier quality tier quantity a lot of our activities uh we're kind of in this losing proposition now now I mentioned that uh we're pretty good at replacing the wet salty part of our teers but actually as an industry we haven't really figured out a how to really effectively replace the oily part and the oils do a few things including when you have a layer of oil on top of a layer of water the water is less likely to evaporate and so the oils help hold the tears on the surface of your eye and so if we're not making as many or as good oils uh as part of our teer film that's uh that's also like kind of working against the saltwater part of our tear um so yeah as an industry as a as a community uh that we haven't really figured out how to get the oil parts Sol for either by effectively replacing the oils or treating our eyelids in a way kind of rejuvenating those o oil glands getting them to kind of go back to their youthful State again you know so the the eyes including the eyelids and the oil glands unfortunately they're aging just like the rest of our body so so this is this this is one of the major features uh is uh is dry eye and and uh and it's tough on patients because you feel it it's really tough because you feel it yeah I have yet another experience to report where when I had the blepharitis which fortunately was transient I also experienced that every time I would blink I could feel the blink and boy I'll tell you I we all most of us take for granted uh what a pleasure it is to not observe the blinking of our eyes because for those I think it lasted about two weeks every time I blink I'd feel an almost sandpaper like experience it was wasn't particularly painful but it was very uncomfortable because you're suddenly conscious of every blink and it's very distracting now that resolved when the blefaritis resolved but I can't even imagine what it would be like to deal with that all day long every day really Dreadful yes it really is and and so you're absolutely right it's a very it's one of our really big unmet needs and and although for most people with dry eye it can be managed with just the regular over-the-counter artificial teardrops you can buy at the GR grocery store over the counter at the pharmacy for a subset of people who have really much more severe symptoms with the dry eye it's it's really it's hard it's a really hard thing to have to live with all the time and and we Counsel on the use of Tears we Counsel on the use of uh eyelid cleaning like we talked about before where you take either these eyelid scrubs or a little dilute baby shampoo to keep those eyelashes really clean that keeps those oil glands functioning at their top capacity for you uh so that you're maximizing high quality teer production reducing inflammation is also important whether that's inflammation from allergy and of course a lot of people's dry eye gets much worse in the spring with seasonal allergies when pollen is around if you have dust allergies in your home uh uh that worsens your symptomatic dry eye um uh or other forms of inflammation there's a there's an element of dry eye that we actually think is inflammation kind of working against our tear glands and and in fact some of the prescription drops now to help combat more severe dry eye uh are anti-inflammatory or even lowd dose steroid types of eye drops um so I think these are all uh sort of Next Generation treatments I think at the at the really Leading Edge of Next Generation treatment is trying to better understand the nerves on the cornea and ocular surface and if there are ways that we could better treat them and help help regenerate and rejuvenate kind of how the nerves and the and the tissue cells are interacting underneath that tiar film and that's where for some patients we can actually use uh either for example blood serum your blood serum is actually very rich in growth factors and many of those growth factors it turns out empirically are really helpful for people with dry eye so if you're one of those people who's been really struggling with with dry eye you might ask your eye care provider hey I I heard about serum tears is that something that could help me serum tears so is this PRP is this platelet rich plasma related but but not the plate platelet rich portion at least not yet they can draw your blood spin out all the cells you're left with the kind of liquid part of your blood that's the serum and then they can dilute that with some salt water maybe with some preservatives in some cases you could keep it in your freezer thaw out the bottle when you're ready to use it you know each few weeks and uh and then then use it just like an eye dropper bottle and those serum tear uh actually can be very helpful for people with with much more advanced or severe hardto control dry eye symptoms uh companies are really trying to figure out hey what are the most important parts of the the serum can we just identify and package just the growth factor and uh and turn that into a product for dry eyye patients and so there's a lot of research on the ocular surface and dry eye going into um going into that space right now I'll tell you the one other recommendation that I always give patients there's a fair amount of evidence that if you're getting too much of some of these preservative chemicals uh which of course if you're going to use an ey drop bottle for a month it should have a preservative in it right so that you don't open the bottle and then it grows bacteria a couple weeks later and now you're you're you're you know you're using contaminated eye drops uh so for bottles it's Ty to have preservatives but I really recommend for patients if they're using anything more than a couple drops here and there uh for their dry eye control to actually go for one of the preservative free artificial tiers they come in lots of Brands I'm sure the house brands at at any of the pharmacies use them too I make them too and these are the ones that come in like strips plastic strips and you break one off you break off the little cap you can use a much as you want all day you have to throw that one out if you have anything left over you have to throw it out at the end of the night and the next day break off a new one because there's no preservatives and once you open it you don't want bacteria to grow in that salt water right um but it's really good because the preservatives can be very irritating or even inflammatory to the ocular surface to the surface of our eyes so we really do want to if we're using more than a drop or two upgrade they cost a little bit more money they're still over the counter upgrade yourself to the preservative free artificial te those are great recommendations I'm also really interested in this serum thing uh because you know were this discussion taking place 10 years ago and I rais PRP platelet rich plasma there would probably be a lot of eye rolls no pun intended because I think myself and a lot of other people in the it's called the sort of standard scientific and medical community looked at platelet rich plasma right alongside stem cell therapies because they were cheek to jowl back then as you recall before the FDA regulations about stem cell claims which we will get to um of course PRP was suggested as a source of stem cells it turns out there are very few if any true stem cells in PRP and yet now as I understand it PRP is an FDA approved protocol for injection into uh the uterus injection into pretty much every tissue and organ system of the body in order to quote unquote rejuvenate it and here I'm not promoting PRP and yet it is a very common practice now in more standard medical clinics but it started off kind of Niche even gray Market kind of underground it's diverged from stem cell therapies and we're going to talk about major modes of vision loss in a moment and this horrible situation that happened down in Florida of a clinic injecting stem cells into patients eyes to recover vision and it actually blinded them so we'll talk about stem cell therapies but for the record is PRP something that's now standard in major opol Opthalmic clinics excuse me including your department at Stanford are you drawing out blood spinning it down taking plasma taking serum and re-injecting it or reapplying it to patients eyes not not yet in Opthalmology uh in eye clinics I I would say we're sort of like right now on the edge of uh groups are starting to study that is it safe is it valuable is it any better for certain conditions like on the ocular surface than serum teers for example this sort of diluting a patient's own own blood serum uh so so it's being studied it's a very active area know it turns out that this PRP uh plasma has uh you know again like a high concentration of growth factors that's probably what's responsible for a lot of the kind of quote tissue Rejuvenation effects uh uh be that be they as they may but but it's being studied but it's definitely not a standard of care yet uh at least in in Opthalmology space and and you know I think whenever there's something really new it really deserves to be properly studied we talked before about you know at first you're going to do trials where you just test it carefully and a few people maybe a few of the most severely effective affected patients be really thoughtful about uh you know the ethics of trying out for safety then as you develop a little understanding of the safety you really want to eventually get to properly controlled randomized what people in the community often call double blind trials but we in Opthalmology like to call Double masked trials blind is a bad word we do blind trials yeah yeah so you really want properly controlled trials testing is it really working is it really deserve the claims that people are making and that has not yet really come to fruition at that level for Opthalmology or I care at so we've been talking a lot about normal visual development ey checks and some of the more typical challenges that people have with their Vision but we haven't yet touched on some of the really debilitating stuff things like glaucoma things like retinitis Pigmentosa macular degeneration the things that if we could we would all avoid and yet are out there in the world at pretty high rates I'm sure you'll share with us what those rates are and as bad as these things are there are ways to detect an offset set their progression so that people don't necessarily lose their Vision so if you could could you share with us what are the major forms of vision loss in childhood and in adulthood and what can each and all of us do in order to find out if we have one of these conditions and therefore treat it effectively yeah that's great you know let's start by just reminding ourselves what are the major causes of vision loss and these are going to differ where you are in the world but the major the number one cause of low vision is actually refractive error people who need glasses and especially in other countries affordability access can't even get glasses okay so that's just refractive error but that's fundamentally correctable the next most common cause of vision loss is cataract cataract is the blurring the Aging of the lens inside the eye behind the cornea we talked about how that is responsible for focusing light under the back of the eye it also has to be clear enough that the light gets through the lens and a cataract is a normal aging process you know as I said if we all live to a 100 or 110 years old we'll all get cataracts we'll all need cataract surgery we actually as you know in the eye clinic we see cataracts years or even decades before they're affecting your vision in a meaningful way so the the cataracts are forming and that's okay but at some point they get bad enough that it's time to take them out we've actually solved for cataract surgery pretty efficiently uh we can do a four to eight minute surgery maybe if we're taking our time it's 10 or 12 minutes of surgical time take out a cataract it works beautifully 99 something per of the time we put a plastic a clear plastic lens inside the eye exactly where your lens used to be and there's even lenses that can Flex or focus light from far and near so cataract is fundamentally a there's still room for improvement but there's it's fundamentally a solved problem uh the problem is is that worldwide there aren't enough cataract surgeons there's not access to care the Machinery or the lenses um cost too much money in developing countries to get out to the number of people who would need them so it's actually just again an access to care cataract is a reversible treatable easily treatable problem but it's number two on the list of causes of vision loss in the world because we don't have enough access to care we need a lot more sort of programming around Global Opthalmology Global Eye Care to solve for cataract uh just to bring that solution to countries around the world then after that you start hitting the eye diseases that LE lead to what are currently irreversible nonreversible causes of vision loss the number one cause of irreversible vision loss in the world is glaucoma so what is glaucoma glaucoma is actually probably a little cluster or constellation of diseases that we lump together it's a degenerative disease like a neurod degeneration we talk about nurd degenerations in the brain like Alzheimer's and Parkinson's glaucoma is a neurod degenerative disease it happens instead of affecting one or different area in your brain it happens to affect the optic nerve that connects the eye to the brain and we need our optic nerves carry all the visual information from the eye to the brain and so if your optic nerve is degenerating in glaucoma and I should add there are other optic neuropathies uh so-called diseases of optic nerve degeneration for example you can get a stroke of the optic nerve you can have an inflammatory disease like multiple sclerosis called optic ntis that affects the optic nerve uh so you can get other optic nerve diseases but glaucoma is by far the most common optic neuropathy and the problem is is just like you know just like spinal cord injury which is also part of the central nervous system right the brain the spinal cord the retin and the optic nerve that's the central nervous system and there's no regeneration and that's why spinal cord injury leads to permanent paralysis while optic nerve injury or op optic nerve degeneration unfortunately leads to permanent vision loss so in the case of glaucoma how do we get ahead of that glaucoma has two major risk factors one is increasing age there are actually infantile and pediatric glaucomas unfortunately and those can be much more aggressive much more damaging when they present so early in kids uh in babies and in children most of the kind of run-of-the Mill glaucoma usually Pres presents in adulthood and even in in the Aging adult so much more common after 50 or 60 or 70 years old increasing the other main risk factor for glaucoma is increasing eye pressure the eye actually you know it stays inflated it's a balloon it has to stay inflated we need some amount of eye pressure to keep our eye as a as an inflated balloon but if the eye pressure goes too high and we we talked about this before you won't even feel it if it slowly gets too high if the eye pressure goes too high that causes glaucoma and um and that's one of the things that we talked about you really include in a comprehensive eye exam when you're just getting a screening checkup at your eye care provider at your optometrist or opthalmologist office they're going to check your pressure and just as a screening tool check to make sure it's not too high we can treat glaucoma today by trying to reduce the impact of that high pressure by lowering the eye pressure so we have treatments for glaucoma that Target the eye pressure we have medications like eye drops we have lasers that can be used inside the eye that can also lower the eye pressure and ultimately if we need them we also have surgeries that can also provide an outflow that lets the fluid out of the eye in a controlled way so that the eye pressure can be brought back down into normal ranges again the reason that glaucoma ends up being the number one cause of irreversible blindness in the world is number one we can't get those therapies everywhere in the world the affordability of ey drops the access to lasers or surgical procedures Around The World Isn't equal to what it is here and even within our country you know people may not be accessing Health Care effectively to get screened for glaucoma or to get treated for glaucoma the other big problem with glaucoma is that it affects our peripheral vision first and only very late in the disease does it pinch in and finally pinch off the center of our vision in typical glaucomas and that's a real problem because we don't notice if our peripheral vision is down you know our peripheral vision isn't that good to begin with and if you're driving and you can see a pedestrian step off the sidewalk you think your peripheral vision is fine but actually your per peripheral vision could already start being damaged by glaucoma and you won't notice it in regular daily life and that's where the importance of screening and early detection really comes in for glaucoma what we don't have for glaucoma we can come back to like kind of what's The Cutting Edge or the future uh in these eye diseases what we don't have are treatments that really Target the optic nerve degenerative process and uh we can come back and talk about that so that's coma and optic neuropathies then the next two major causes of currently largely irreversible vision loss are age related macular degeneration and then diabetic retinopathy now age related macular generation is just like it sounds major risk factor is age it's very common and actually in the developed world you know countries that are more developed also countries that have a larger Caucasian white population it's more common in certain populations than in others um it actually is you know definitely a leading cause of vision loss in the elderly population for example in the United States um and uh there's two forms of macula degeneration but they both end up targeting the same part the same part of the retina and that part of the retina is really like the rods and the con that we talked about before the rods do your low light vision at nighttime uh primarily your cones do color vision and bright light you know sort of normal lighting uh that we experience you know through most of our awake day and in that back of the retina you can have what's called dry macul degeneration which is a slow thankfully slow but slow Insidious disease that causes the degeneration of the rods and cones and also the support cells that help feed the rods and cones and take care of the rods and cones they're called RP cells retinal pigment epithelium it's not really critical of course uh the names of every different cell type but these are like the the the light collecting cells in our eyes and the retin and they degenerate in macular degeneration and in the dry form there's this slow degeneration but some percent of people with the dry form of macular degeneration will actually convert to What's called the wet form it's called wet because new blood vessels actually grow inappropriately under and even into the retina and new blood vessels unlike our mature blood vessels tend to be leaky and so that the fluid leaks out of those blood vessels gets into the rtina interferes with vision and that can lead to a much more acute loss of vision now we have some treatments for wet macular degeneration we have injections that go can go into the that actually fight against the molecules that are causing those new blood vessels to grow and these are antibodies that can be injected into the eye and they can be very effective controlling patients wet macul degeneration it's been a much bigger uphill battle even over the last decade of as advances are being made to to really try to knock back or or or slow down even the dry form of ma degeneration there was just some exciting news even just in the last few months the first uh successful Trials of a treatment for the dry form uh have just shown success in properly randomized controlled human clinical trials phase three clinical trials so it's an exciting time those new treatments are not going to be a Panacea they slow the progression like the an anatomic progression of the disease uh maybe by 20 or 25% so so patients are still going to get worse even with those treatments so there's still a lot more to be done to really knock back macular degeneration I want to mention you mentioned retinitis Pigmentosa that's like an inherited form of a type of macula degeneration it's also affecting the rods and cones and also the support cells the rpe cells in the back of the eye reiz Pigmentosa is an inherited form there are actually many different genes you could have that could leave to reiz Pig Pigmentosa in aggregate if you add up all the people with all those different genes uh and and it can be very devastating because it can really affect the vision knock out your vision very early in life including in children and even versions of that in babies but you add that all up it's still much less common and aggregate than macular degeneration but in a way it's you know quite a bit more severe because it does affect people much earli in life so so I sort of clumped those together Mac degeneration retinitis Pigmentosa degeneration of the rods and cones and the support cells the rpe support cells and then you you can't have this part of the discussion about what are the devastating eye diseases without bringing up diabetic retinopathy especially because diabetes unfortunately really continues to grow in especially let's say in the United States certainly in the developed world you know as we um especially type two diabetes with eating habits exercise habits contributing to a proliferation of some of the risk factors for type 2 diabetes metabolic syndrome obesity um we're unfortunately seeing a proliferation a growth in the number of people with diabetes and with the growth in diabetes unfortunately comes a growth of the complications of diabetes and one of the major complications of diabet abetes is damaged to the retina inside the eye and we call that diabetic retinopathy uh and there again some of the same damage that occurs especially when in diabetes again some new blood vessels are growing or blood vessels are leaky some of that can be treated with used to be lasers and now more commonly is often being treated with some of the same injectable drugs that are treating macular degeneration um but there's still a lot lot of vision loss with diabetes and diabetic retinopathy I think that's an area where again early screening making sure if you have diabetes that's that's an indication where you definitely have to be going in and getting your an at least annual exam with an eye care provider or having someone take a photograph of the inside of your eye and rate that photograph to say if you have any diabetic retinopathy or not in terms of interventions can we talk about diabetic retinopathy first because because of course type 1 diabetes is a failure to produce insulin relatively rare compared to type 2 diabetes which as you mentioned is proliferating in developing countries right this is probably unprecedented in the sense that developing countries have better Medical Care typically than non-developed countries um more opportunities for food nourishment and yet it's clearly a problem of overnourishment um insulin insensitivity obesity Etc is this type of diabetic written opathy that one observes the same for type 1 diabetics versus type two diabetics because my understanding is that type two diabetes this insulin insensitivity is a bit of a Continuum right I mean the type 1 diabetes is as far as I know is all or none you either make insulin or you don't but type two diabetes someone could be mildly in insulin insensitive or severely insulin insensitive and sometimes I'm told people are not necessarily obese and can have type 2 diabetes as well um certainly things like smoking and alcohol intake can contribute to that so how equivalent are type 1 and type two diabetes when framed Under the Umbrella of diabetic retinopathy yeah the the the time to presentation can be different uh a type 1 diabetic usually presents with sort of a cataclysmic sudden loss sudden sort of final loss of their ability to make insulin it usually presents in childhood or teenage years but can present you can have late on set type 1 diabetes because it's kind of a sudden presentation it can take some years after that to show any diabetic retinopathy whereas just because just just like you said type two diabetes can be on a Continuum and people can have like kind of a mild type two diabetes but kind of be you know getting along you know going through life kind of maybe not even realizing you know at first and so when you're diagnosed with type 2 diabetes you've probably had some insulin resistance for the years prior to your diagnosis and so in that case you often can have um you know like you're you're at higher risk for presenting sooner with the the complications of diabetes like diabetic retinopathy now given that the actual retinopathy is very similar maybe the same uh between type 1 diabetes and type two diabetes and again it involves things like leaky blood vessels new blood vessel growth there's some amount of neurod degenerative dysfunction that just simply occurs uh so so uh you can have little little hemorrhages or bleeding spots in the retina tiny little strokes or microvascular uh uh events in the retina uh so that can happen in either type 1 or type two diabetes one once you start having the retinopathy it does look pretty similar so what can people do to prevent or treat diabetic retinopathy obviously the type 1 diabetic needs to take insulin in order to survive really uh type two diabetics need to get their obesity under control if they are in fact obese and get their blood sugar levels under control uh regardless uh that's my understanding and by extension are you seeing any reductions in diabetic retinopathy with people that are taking these um glucagonlike peptide mimics um like OIC which is used to treat type two diabetes yeah it's been a very exciting development for the diabetes field uh this new class of of um of uh anti-diabetic drugs and um so uh there you've touched on a couple of them there are a few key things uh for reducing the risk of diabetes or the impact of diabetes on your retina uh at risk of diabetic retinopathy uh or impact of diabetes on your retina uh one is as I mentioned get regular eye exams be screened you know any diabetic should be screened at least once a year uh with a with a good comprehensive retinal exam looking for any of these uh items the number one most important element to prevent diabetic retinopathy is to control your diabetes and having a real good blood sugar control keeping your hemoglobin A1c which is one of the blood tests that gets used to measure how your kind of long-term diabetes management is going uh that's really uh you know first and foremost the most important and that's been shown in large clinical trials they actually randomize patients to hey take care of your diabetes or do a real good job taking care of your diabetes and the patients who did a real good job taking care of their diabetes have much less diab diabetic retinopathy so that's number one it turns out that if you have high blood pressure and diabetes that blood pressure is also really damaging to your retina also by the way the kidneys and probably all the other organs that are suffering from the diabetic insult so in addition to controlling blood sugar really important to have blood pressure under great control now both blood sugar and blood pressure in type 2 diabetics especially if you're cat tching them early can be improved with some of these you know so-called Lifestyle Changes like improving eating watching what your food intake is you know getting good exercise trying to lose weight uh so uh these are definitely on that list of how do you get to good blood sugar and blood pressure control but suffice it to say blood sugar and blood pressure control right at the top and then also including the regular at least annual exams and then if diabetic retinopathy is detected and blood sugar and blood pressure control are not going to be enough for that patient we do have treatments as I mentioned before there are drugs that can be injected if your retina is getting you know kind of leaky blood vessels from diabetes uh there there are treatments that we can give the eye specifically to try to counter the diabetic retinopathy terrific in terms of glaucoma as you mentioned glaucoma is related to pressure although there is pressure normal glaucoma glaucoma is a death of the retinal gangling cells the neurons that connect the eye to the brain and once they are gone at least at this point in human history they can't be replaced although hopefully because of work that you've done and that other Laboratories are doing at some point that statement I just made will not be true and the rgc's can be replaced meanwhile what can and should be do to find out if they have glaucoma and to treat glaucoma and is it true that even if somebody has normal pressure that lowering their eye pressure further protects them against glaucoma yeah that's absolutely right so most important is to get screened with a formal exam at your optometrist or opthalmologist because you you won't notice you won't have any symptoms if your eye pressure is too high you won't not you're not likely to notice until very late in the disease if your peripheral vision is being damaged through the course of glaucoma so most important as to have a screening exam a good comprehensive screening exam will always include checking the eye pressures and also looking in the back of your eye the head of the optic nerve where all the fibers leave the eye and carry the optic nerve information back to the brain we can see that when we look inside your eye and uh and and glaucoma has a fairly characteristic look to it in the optic nerve head so so looking at the optic nerve head uh we have Imaging and peripheral vision testing that can also be included in those screening exams so if you really get a comprehensive screening exam you can very reliably detect if you have glaucoma to worry about or you're in the clear if you have glaucoma to worry about we have treatments and you're absolutely right whether you start with a abnormally high pressure or you start with a pressure that's on the face of it in the normal range in either case lowering the pressure has been shown in large properly controlled clinical trials to slow the progression of optic nerve damage and vision loss so absolutely in either case starting with high pressure or starting with normal pressure in either case you've got to lower the pressure further and as I mentioned we have ey drops those are usually the first line there's very good data that there's a very benign non-invasive laser it's not the same kind of laser that gets used for lasic but there's a benign very safe type of laser called selective laser tcul plasty SLT we call it and that's also very effective as a first line actually in the largest clinical trial uh from which the data have been coming out just even over the last few years it's called the light trial uh in the light trial patients with glaucoma were randomly assigned to either get the laser or the sort of most common first strongest eye drop and uh uh that gets used clinically and actually on many features they both worked at least as well but when looking out over the long term actually the laser had some advantages over the eye drop not in the least of which by the way it's very nice for patients to not have to like remember to use the eye drop every night and so um so that's quite helpful I think uh to to keep in mind as a treatment option uh early in the the disease of course if the ey drops Andor lasers are not enough early in the disease we also have surgical approaches to lower the eye pressure further you know even with all of our treatments all of these treatments stepping patients through all of this about 10 15 even 20% of patients will lose very meaningful functional vision and maybe 5 10 15% of patients especially depending where you are in the world will will go blind from glaucoma um including in you know quote unquote developed countries uh there's still a very significant cohort of patients that go blind legally blind and then you know absolute blindness I can't even tell if the lights are on in the room uh so it's it's it's devastating it's Insidious it's hard to detect early um and uh so glaucoma is still a tough one even with all of the treatments that we have okay so get your pressures checked folks and if you are prescribed drops take your drops I hear about patients not taking their drops which to me just seems like baffling but I guess having to do something day in and day out is can be Troublesome enough that unless people are losing their Vision very quickly or they are very afraid of losing their Vision sometimes they just neglect to take them it's hard it's hard for glaucoma eye drops it's hard for taking your blood pressure medication it's hard for a lot of medicines you know if you're if you're taking a medicine where you don't feel better you know if you have a headache and you take an aspirin or Tylenol or an ibuprofen uh you know you feel better you feel reinforced gosh taking that pill made sense right uh but if you're using an ey drop that like hey this is going to protect you for the next 20 years from losing your vision but you don't notice every day that anything's better and by the way the eye drops could be a little irritating maybe it stings a little for a minute or two when you put it in your eye some people are even less tolerant of the eye drops it's hard to feel motivated every day and we know that we call that compliance we know that it's very hard for patients to stay complying with prescribed medications where they don't feel or notice a difference in a daily way I realize that we can't stop aging yet um but right now you can't stop aging and age is a risk factor for glaucoma my understanding is so is smoking or vaping nicotine and so is alcohol and by that reasoning should people strive to drink less and smoke less including vaping nicotine less if they are concerned about glaucoma yeah and not just glaucoma macular degeneration actually macular degeneration has a couple major risk factors macular degeneration aging just like with glaucoma major risk factor smoking including exposure to second hand smoke major risk factor for macul degeneration and for the progression and vision loss potentially associated with macular degeneration in the case of macul generation there's also a couple of genes that we've sequenced the human genome and there's a couple of genes associated with macul generation too that's less true for your typical run-of-the-mill adult glaucoma there are genes for the Pediatric and infantile forms of glaucoma uh so yeah smoking 100% including vaping uh it's a no no for your eyes just like it's a no no for the rest of your body and uh it's tough as the eye doctor to have these conversations with patients because you kind of feel like well you know they must know it already and I'm trying to be the good guy in the room with the patient convince them to use their other medications but I it's it's important for us also as Eye Care Providers to reinforce the message with our patients a smoking terrible idea uh for macul degeneration also for glaucoma you know glaucoma's interesting because the optic nerve where it degenerates kind of right at the head of the optic nerve where it where it exits the eye it's what we call a watershed Zone it's kind of the edge of two blood vessel supplies and if either of those blood vessel supplies are a little bit short on blood or oxygen supply to that optic nerve head your glaucoma is going to get worse your optic nerve is going to be underfed and that's going to worsen this degenerative process just by not having all the right nutrients and oxygen so the other thing is that especially for glaucoma everything that we talk about for being heart healthy for the rest of our body is is almost certainly true for glaucoma and so I also always counsel glaucoma patients it's not just no smoking but eat healthy have a multivitamin uh get some exercise all those things that are good for your cardiovascular system are going to be good for your eyes in general and in particular if you have glaucoma uh or risk high risk for glaucoma I realized that smoking or vaping are problematic for glaucoma and for macular degeneration but we can't have a conversation about glaucoma without at least mentioning cannabis uh I did an entire episode about cannabis which touched on some of the real dangers of very high THC concentration in cannabis this lost me a few um followers I'm sure no problem because what was important was to convey the fact that the Cannabis that's out there nowadays comes in a variety of different strains and ratios of THC to CBD there's some severe risks of high THC especially in young males um although not always the point being that there are I want to be very clear about this because for whatever reason cannabis gets people really up in arms they always say it's not as bad as alcohol but guess what we did in the entire episode about alcohol and there the message is very clear zero is better than any and two a week is probably the limit and if you're an alcoholic zero is the rule so with cannabis it's clear by my read of the data that it can lower eye pressure which may undermine the progression of glaucoma somewhat but if people are smoking that cannabis is it therefore going to offset any gain that one would get from that cannabis and then how does one account for the potentially problematic aspects of very high THC cannabis yeah it's a great question and the truth is is that in most patients cannabis will lower the eye pressure the problem is is it really only lowers that eye pressure During the period that you're high from the Cannabis and the second problem is that smoking version of getting that cannabis into your system the smoking is bad for your lungs by the way the smoke from Cannabis or from cigarettes is also terrible for your dry eyes uh it causes inflammation it dries out your eyes so it's also very bad from that perspective now so the problem with cannabis is not that it doesn't work to lower the Press we want to lower the pressure that's great the problem with cannabis is that it's not realistic for most of our patients to prescribe could you go out and be high from Cannabis 24 hours a day seven days a week for the next 20 years I'm sure some people have tried and succeeded um but right that's not practical for most people and certainly for young people it could be really especially problematic I should say absolutely so so I recommend not taking that approach but that said I am definitely not a decer of it and now that there are edible forms I certainly have patients who are using it in a responsible way uh especially edible forms and uh and in select cases like that could make the difference for them helping to keep the pressure down and I'll say for example you know it turns out you you've talked a lot over the last couple years about dial curves and circadian rhythms it turns out that our eye pressure also under goes the Circadian rhythm and it's actually highest at night while we're sleeping kind of peaks in those early morning hours then hits a low throughout the early day and then kind of rises again throughout the afternoon into the evening and uh we have a lot of patients who they come into their Clinic visit their eye pressure looks normal but it's actually quite a bit higher when they're at home and that could explain some fraction of what we call normal pressure glaucoma it just looks normal during the day it's actually high at night and so in particular some patients I certainly have some patients who are using these products like let's say before bed and if it's controlling their eye pressure at night while they're asleep when the eye pressure would have been the highest it may confer some protective advantage over time but that's said again like for most patients it's not going to be the primary approach I'm most excited about the idea of uh um you know Laboratories or companies figuring out which the compounds Within These uh cannabinoids they're called within these products are actually responsible for lowering the eye pressure and could we get like a more potent eye specific longacting drug that's basically derived from the concept of cannabis but works better and is more compatible with not bringing along all the other adverse elements that can come with cannabis use you mentioned the Circadian rhythm and eye pressure and the fact that eye pressure is higher at night is there any advantage to sleeping in a particular position I know this might sound a little detailed but I seem to recall an abstract or a paper a few years ago at a meeting that you and I both attended where that said that if people slept with their head below their feet uh eye pressures were higher than if their head was slightly elevated above their feet and for somebody who has glaucoma this could make pretty substantial difference in terms of their eye pressures at precisely the hours of the night we should say in which they could be doing the most damage to the gangan cells yeah absolutely and we will sometimes counsel patients with severe glaucoma especially if they're you know poorly responsive to standard therapies or poorly able to tolerate standard therapies we'll counsel them if they're able to sleep up on a couple pillows get kind of a 30° sleep angle going what I don't want to do is interfere with a person's sleep because I just I fundamentally feel for the total health of the whole human being getting a good night's sleep is maybe more important than that 30 degrees and if trying to sleep up on pillows at 30 degrees is going to lead to kind of restless difficult sleep night I'd rather the patient get a good night's sleep but if they can tolerate it and especially if they have a sort of a a tough version of glaucoma then we'll we'll we'll let them try see if they can sleep up the other really interesting question that arises is uh does which side you sleep on affect uh which eye might have worse glaucoma glaucoma is almost always with with a few rare exceptions almost always a disease of two eyes but it can present very asymmetrically in fact it's quite common to have one eye kind of have worse damage than the other and and we don't know fundamentally why that is but one hypothesis was gosh maybe if you sleep on the right eye uh then your right eye will have worse glaucoma because the pressure is a little higher down below or maybe it's pressing on the pillow in a way or something like that there have been a couple Stu studies really really looking at that question a couple Studies have said the lower ey will have worse glaucoma couple Studies have said the higher I will have worse glaucoma so the upshot is it probably doesn't matter which side you sleep on we also know when you video people in their normal sleep pattern even if you feel you always fall asleep on the left side of your face people toss and turn all night probably over the course of the night you're spending a similar amount of time on each eye I'm glad you brought up that point in terms of macular degeneration I'm curious about the things that people can do as opposed to the don'ts in order to perhaps offset macular degeneration one of the things that I'm intrigued by are the results of Glenn jeffy's laboratory over at University College London I had known Jeff for probably a decade or more and he typically worked on animal models but then a few years ago started publishing studies and I believe there are now two published studies showing how red light exposure and near infrared light exposure done early in the day to the eye at a distance of about 2 feet for just a couple of minutes a few times a week could offset some of the vision loss associated with age related macular degeneration in people older than 40 that's my understanding of these studies and there's a theory there about enhancing function of mitochondria and photo receptors by reducing reactive oxygen species there's a whole mechanistic hypothesis but my question is is that the sort of protocol that produces significant enough offset of maca degeneration like we should all be looking at red lights in the morning um or is it still too early days in order to really conclude that I I I think the data is very compelling the data are ve very compelling that this kind of red or near infrared light therapy uh can be at some level neuroprotective and yes the the data suggests that uh kind of ramping up high high functioning mitochondria is a part of that uh activating neuroprotective Pathways in the retina it's actually been demonstrated in animal models and a little human data here and there but both for macular degeneration kind of uh degenerative dis but also for optic neuropathies you know like gloma retinal gangan cells the cells that carry all that visual information from the eye to the brain they're chalk full of mitochondria too and uh and so the idea that this could be a therapeutic approach I think is very compelling there are a number of studies actually I think still ongoing today really trying to figure out what's the right dose how much brightness do you need is there an optimal wavelength how many minutes does it matter when during the day you provide that light or how many minutes or hours um these are still very much open questions you know what's the dose what's the delivery um but it's it's it's it's very promising looking and there's biological premise and I'm excited to see where that goes because again that's like a that's a very accessible uh sort of therapeutic approach that could be brought to a very broad swath of of people so I'm excited about that sorry I didn't mean to interrupt and completely non-invasive um I should um probably mention a warning which is if people are going to decide that they're going to jump on this result and do red light exposure in the early part of the day no matter what color a light is if it's too bright you can damage your eye so I think this is why you're pointing the fact that we need established protocols um before people really start blasting their eyes with red light and if they are going to expose themselves to Red Light it shouldn't be uncomfortably bright do I have that correct yeah that's absolutely right you know actually uh light effect um we talked about this a little bit earlier um there's actually now data also that red light and actually interestingly studies using light at the other end of the visible spectrum violet light either of those in small daily doses can also be used to prevent progression of nearsightedness in children in school AG children and so uh I think we're really just on the cusp of really understanding the biology of how these different light therapies might be leveraged maximally to to maximize our Eye Health uh and both during development and at the other end of the spectrum uh as we age um so it's an exciting area and I think this kind of photo therapy is uh you know um a very hot topic for research right now very hot topic one has to wonder whether or not these light therapies the fact that infrared works and maybe ultraviolet works is are really just capturing some of what sunlight is naturally doing when as you mentioned before a child or perhaps an adult also spends a certain number of hours outdoors I mean maybe we're just filling in the blanks that are neglected nowadays because we're spending so much time indoors under artificial lights and in front of screens yeah yeah that's yeah very thoughtful possibility yeah I have a couple of we don't have to call them quick questions but common questions that perhaps have a brief uh explanations uh for instance I put out a request for questions in anticipation of this episode and I got a lot of people asking what are floaters in the eye and is there anything that people can do to get rid of floaters yeah our our eye when we're born is actually filled in the middle of with a a jelly it's not just fluid it's kind of a jelly there's collagen fibers and thankfully the whole jelly is largely invisible so the light can get through our eye back to the retina without being impeded as we age those different fibers and gels shrink and contract and they peel off of the back of the retina so there's just in the middle now your your your eyeball doesn't shrink because it fills in with with fluid with saltwater basically but the gel part shrinks and as it shrinks and also pulls peels off the retina uh it can pull off kind of little tiny retinal bits not important to your vision bits but just like little tissue bits and also as it congeals it kind of uh can get little concretions in the jelly and we perceive those as floaters you know little almost semi-translucent or in some cases kind of grayish blackish sometimes sometimes you get a big one if it peels off the of the optic nerve in the back of the eye as happens we call that a posterior Vitus Detachment you can actually see like a moon or a half moon floer uh in Your Vision these are very frustrating to a lot of people um and uh the good news is in almost all cases they will just go away by themselves in theory it's been played with gosh we could do like a big surgery to chew up all that jelly replace it all with salt water try to get of your floaters there's risk associated with that surgery we use it very effectively in retinal detachments or other diseases bad diabetic retinopathy bleeding inside the eye we can take out the jelly from the eye replace it with with with salt water uh but that's not um you know putting patients through the risk of that surgery just to get rid of a couple of floaters or a few floaters that probably are going to go away over the next few months I actually like to tell patients it's nothing to worry about just ignore them and actually if you stop focusing on them your brain will actually start filtering them out you'll stop noticing them if you can kind of uh not worry about them be a little intentional about ignoring them in the beginning and then they do actually go away and look some will go away these three will go away these two will appear uh eventually you'll stop having floaters most patients will stop having floaters um so we really don't like to put a patient at risk by intervening we really like to in this case just reassure them it's going to be okay just ignore them they'll eventually go away thank you for that answer twitching of the eye is something that people complain about I know when I get tired I'll get a twitch over one eye I think there's a condition is it called myena gravis where people go through a stressful period or get very fatigued and I think that's a depletion of the nerve terminal communication between the nerves that control the muscles of the eye and then people get this kind of like hooded eye look um where they have a hard time opening their eyes but barring something extreme like mytina gravis or staying up for two days working or even just being a bit sleep deprived what causes the twitching of the eyelid and is there anything people can do about that most of the time it's actually just a bad nerve ending you know uh maybe that one nerve cell you know your eyelid is fed by you know hundreds maybe it's thousands of nerve cells that are doing the muscles they're doing the feeling obviously it's the ones controlling the muscles that can lead to a twitch if one of those nerve cells kind of just starts you know maybe that one nerve cell is dying just you know whatever the aging process uh you know it happens in young people too though so you got one bad fiber that's just deciding to kind of ring off the hook that's that's that telephone is just ringing off the hook and it's just activating the muscle so you're just twitching that muscle um I've had them as well and you can have them not just in your eyelids you can have this anywhere in your body like one little spot on your leg where just the muscle right under the skin is just and typically it'll happen over the course of a couple of months uh intermittently some days more some days less maybe it correlates with when you're tired a little bit sometimes um and then it'll stop that nerve cell will either reconnect properly and stop doing that maybe it dies we don't really know but typically at lasts on that scale now there are other diseases not just myasthenia gravis you can have bleros spasm like where you have a chronic spasming of of of certain nerves causing muscles to spasm and there we we can use we can use treatments for example Botox is a treatment that uh you know people use for cosmetic reducing of wrinkles for example but you know a really good medical use of Botox is preventing that Leos spasm and patients can come in once every 3 or six months if they have a really severe spasming version of what you're describing but the regular occasional run-of-the-mill lasts a couple months nothing to worry about it does not pre- anything bad happening in your future and uh maybe let it run its course and you'll be okay great we've all heard that carrots are good for our vision which presumably stems from some peripheral understanding about the fact that vitamin A is integral to the photosynthesis pathway of converting light into electrical and chemical signals that the rest of the ion brain can use and yet I'm guessing that there probably aren't that many people walking around who are vitamin A deficient they're probably out there but not that many especially in developed countries and in addition in the last really five years but in particular in the last two years I've seen a proliferation of supplements on the market to promote Eye Health and longevity of vision I'd love your thought on this General theme of nutrition and supplements for improving Eye Health or for maintaining Eye Health and before we started recording you mentioned that Opthalmology or at least Eye Health is one area of medicine that has a bit not extensive but a bit of a longer history of exploring supplementation in rigorous randomized control trials whereas other areas of neuros science and Neural Health such as Alzheimer's Etc certainly there are brain health supplements out there but there aren't a lot of rigorous data to support them just yet so what are your thoughts on nutrition um aside from the standard thing of you know people shouldn't be ingesting too many calories such that they are obese and diabetic and therefore you know Etc indirect effects of nutrition um what are your thoughts on nutrition and supplementation for Eye Health yeah you know you're absolutely right and again in Opthalmology we actually do have quite bit of studies there's been quite a bit of attention over the years even over the decades looking at this question and I think it's worth highlighting um a couple of yeses and a couple of NOS for macular degeneration which we talked about being an exceedingly common cause of vision loss uh there have been two age related eye disease studies called AIDS age related eye disease studies arids there was arids and then arids too and those studies were large randomized Trials of using giving giving patients supplements and in arids it was vitamin c and e uh higher dose than would just come in a multivitamin zinc and copper and then also beta carotene and betacarotene is one of these what are called carotenoids it's a it's a if you look at the extended family there's maybe 600 different chemical entities of these catenoids and betacarotene is one of the that's in the direct pathway of making vitamin A and so that was the principle in the aid study and the aid study showed that patients randomized to these pills compared to controls it it did the these are antioxidants in part right in addition to feeding into that vitamin A pathway and um and the patients randomized to get that supplement mixture showed less progression of their dry macular degeneration in the moderate to severe range es if you had mild macul degeneration they didn't show a statistically significant Improvement but I will say it's my experience you know myself with patients and and seeing how the field works you know if you have mild macular degeneration even though it's not as clinically proven we're still often recommending hey if you can afford that supplement go ahead and buy that now irids Was Then followed by a second study irids 2 also with vitamin C vitamin E zinc and copper they actually tested whether a slightly lower dose of zinc would be as good as a higher dose and a lower dose was as good as a higher dose and then instead of the beta carotene they tested against the betacarotene they tried two other carotenoids that are called lutein and zantin and and they actually found head-to-head that the second the AIDS 2 formula without the beta carotene and with the ltin and xanthine uh that that formula was even better at slowing dry macular degeneration in the moderate to severe population again it's not clear how much it may help mild macular degeneration but in the uh sort of clinically defined moderate toward severe group there was a statistically sign it reduced it by about 225% the progression of your dry maage generation and you know over a couple of years 25% you may not notice but over a couple of decades you know that could really slow down the progression of your disease now it turns out that the beta katene they noted a little bit of an increased cancer risk in the patients in the arids one who had that beta keratin mostly in patients who are smokers they also noticed in the second one that if you were already not taking a multivitamin or not eating a diet that's already naturally rich in ltin or zaz xanthine that the effect of that supplement was even stronger so it was very strong clinical trial support for taking what we now use this arids 2 supplementation and I'm sure we can list the formula or put it in the links under under under your podcast uh uh that that this really does slow maculate degeneration so that's like a very strong example of a yes you should do this there's one yes brewing in the glaucoma field right now and that's high do vitamin B3 is in boy 3 it's also called in its various forms either nicotinic acid or nicotinamide uh the nicotin sounds like nicotine but this is not a substitute for smoking or vaping this is a different this is a vitamin that just has a very similar sounding name it's in the NAD synthesis pathway correct that's exactly right it's in the NAD pathway NAD is one of the oxidative stress regulators and energy Regulators of our cells so it's a very critical molec in the metabolism of our cells and there was very strong evidence in preclinical models of mice given glaucoma that manipulating this pathway and and sort of increasing this pathway could be protective in glaucoma or other optic neuropathies optic nerve degenerative diseases and so there have now been two limited but randomized controlled clinical trials one looking at glaucoma patients looking at their visual so they're actual visual performance and the other looking at the electrical signals in the eye called an electroretinogram kind of like an EEG does for your brain we can do an ERG for your retina and in both of those trials high do vitamin B3 was a found to be very safe and B was shown to actually improve at least in the short term improve retinal function measured either on visual field testing or on uh the electroretinogram now this is now entering clinical trials large kind of phase three style clinical trials actually around the world it's a very hot topic for glaucoma the fact that this NAD boosting supplementation with high dose vitamin B3 might be a great approach to helping Pro protect the nerve in in glaucoma and uh so as I say there's there's three or four large randomized phase three style clinical trials uh starting now and so over the next year or two we'll get more data um but I'll tell you like I have patients and if they're at the end of their rope and we are having a lot of trouble controlling their vision loss from glaucoma I'm already recommending in these limited cases uh hey why don't you try this it's almost certainly safe uh and it may and it may help and it may help protect your vision over time so so that's that's an area that's kind of another like kind of could be a yes early dat is pointing in the right direction you want to be careful but uh but I but I am starting to recommend it at the same time that we're actually doing the clinical trials now that said there are a lot of other things that people talk about other supplements Geno balua uh things with generic names on the internet like you know glaucoma preservation uh yeah that sort of thing makes my uh gives me hives you know yeah and and these are areas where there might be scientific premise like a plausible explanation for how this should help but not good data that it actually helps thankfully in most cases these things are safe uh but I just worry about patients hitching their wagon to something that's not going to help them getting their hopes up uh worst case scenario not taking their actually proven prescribed treatments and instead using an alternative therapy that doesn't have data to support it and so I think there there's a lot of you know um uh uh you know either un unfounded unsupported uh you know information it travels around chat rooms travels around the internet one person tells the next person you know there's inappropriate advertising for some of these uh and there you know I really don't want patients to be hurt not necessarily hurt by taking something that's not helping but but maybe hurt by feeling like ah I don't have to go to the doctor I'm taking this supplement and that would be obviously a really bad potential outcome for a patient yeah I completely agree uh supplements are just as the name suggests a supplement to an already hopefully healthy lifestyle and use of medication where it's prescribed and uh I've often said on the podcast that um Sometimes the best dose of a supplement is zero milligrams um um so I do appreciate you touching on those themes because um supplementation is something that comes up from time to time on the podcast and I know that I've certainly have seen a number of these different ey andv Vision support supplements we aren't affiliated with any of them um I don't personally take any of them but these clinical trials sound promising so I'm going to um keep an ear to the ground uh for them as a final question and hopefully a topic that we can cover in more detail in a subsequent episode of the podcast because I absolutely want to have you back to discuss this in more detail I'd like to just get your thoughts on the fact that the neural retina is in fact neural and it's part of the brain and we are hearing an increasing amount of positive chatter about the use of Imaging the eye and the retina directly as a way to detect other forms of neurod degeneration for those that are listening or for watching um you know I'm putting my hands up in a kind of C shape back of your eye is lined with these with this three cell layer thick thing that is the neural retina which are really pieces of brain that connect to the rest of the brain and because it resides in the eyes and outside the cranial Vault people like you skilled clinicians with the appropriate tools can look into the eye and see the brain directly without having to cut through the skull and my understanding is that more and more opthalmologists are seeing cases where degeneration of the retina is correlated with degeneration of structures deeper in the brain making Imaging of the neural retina perhaps one of the best diagnostic tools for predicting and tracking the progression of Alzheimer's and other forms of neurod degeneration do I have that right yeah absolutely actually this is a super exciting area you know we we have this long-standing saying in Opthalmology that the ey is a window to the brain the eyes is a window to the soul of course is a longstanding saying right and and it turns out that you know in Alzheimer's disease as an example you know we really talk a lot about the degeneration of Basil forbrain colonic neurons that are leading to the cognitive deficits in Alzheimer's disease but it turns out that there is also some degeneration throughout other areas of the brain including the retina and since we have such a relatively easy time Imaging the retina you can go into your doctor's office and get a quick little uh sort of laser scan of the retina a picture of the retina compared to like going through a full MRI process for your brain uh and we can detect the degeneration of the retina optic nerve associated with Alzheimer's disease it looks like the same thing is happening in Perkins disease and Ms now one of the issues is that in a lot of these degenerative diseases we're we're able to detect the difference in the retina but we're not necessarily able to say hey if we see this in the retina it's multiple sclerosis but if we see that in the retina it's Alzheimer's disease so there may not be there may be good sensitivity to detecting the disease and to following whether your diseas is your brain disease is getting worse but there may not be very good specificity differentiating the different diseases and I say that with a very big asterisk at the end of that sentence because there's actually amazingly cool new data one of our colleagues who you know Al dubra has helped revolutionize a new way of iming the retina that's giving us now cellular resolution and even subcellular resolution seeing things smaller than the sizes of cells inside our retina and recently in one of his projects he's teamed up with another one of our faculty Heather Moss she's a neuro opthalmologist so she really specializes clinically in the eye brain connection and her research focuses on that and together they made actually an amazing recent discovery of very special ized unusual novel structures that they can detect in the retina of patients with multiple sclerosis and whether these kinds of discoveries or other similar kinds of discoveries are going to lead to kind of a a whole new generation of biomarkers which are ways of measuring disease diagnosing who has the disease figuring out who's getting worse from the disease figuring out who's responding to therapies that we're trying to use to treat the diseases this is a very exciting area and this really touches on what we're all hoping is the future of of eye care as well as the rest of medicine and that's that's Precision medicine but also what we call Precision Health we really want to not just figure out what drug treatment to give this patient versus that treatment but we really want to figure out who's at risk of even getting some of these diseases and gosh we could intervene now and prevent them from ever getting in trouble in the future fantastic can't wait to hear more about those developments and listen I want to say on behalf of the listeners and myself just thank you ever so much for the discussion today I don't think I can ever recall a conversation that's included so much basic science and clinical science and also so many actionable recommendations both dos and don'ts as it relates to something so critical as Eye Health I also was just reflecting for a moment about the fact that I think you and I met 20 years ago when you were a graduate student by the way folks um Jeff is uh sort of the Kobe Bryant of sort although unfortunately still with us in the sense that he went directly from his MD and PhD skipped his postdoc didn't require one directly to being a faculty uh member most people don't do that they do a five-year postto in between wait and then I believe he's going to tell me all the places I'm wrong and I should just come clean that um Jeff is my chairi of department at um Stanford School of Medicine Department of Opthalmology so for me I I see this as a particularly warming but also um at once predictable but pure pleasure of an experience to get to learn so much from you because I don't think we've had this long to sit down and talk science in a very long time so thank you for doing that for my own sake thank you for teaching us so much about how to take care of our Eye Health and now you can tell me where my um history is wrong maybe my hippocampus is degenerating no it's been a pleasure over the years I have nothing but the warmest memories of of you as a postto and me as a graduate student getting to be you know nerds in the laboratory uh years ago 20 years ago uh at Stanford in the lab of Ben Baris and uh and very warm wonderful feelings about you know learning science and how to do science and making real advances even at that time and then the fact that we've had the chance to cross paths in San Diego again at Stanford collaborate on important projects having to do with you know developing new ways of measuring diseases developing new ways of treating diseases the idea that we're going to actually bring forward some of the advances uh that our lab that your lab that other people's Labs have been making in neuroprotection in diseases like glaucoma and Mac degeneration in regeneration of the optic nerve of the retina uh we are real close on a lot of those this is a major topic of really The Cutting Edge research that we're really trying to keep pushing forward because we know it's so important to patients you know I I often joke you know my mother had a uh a sign outside the bathroom and it said remember how long a minute is depends on what side of the door you're on and I really appreciate that like as fast as we're trying to go with our research and moving that into clinical research which I think we're doing very effectively in the department really working on Vision restoration research in the department I appreciate that as fast as we think we're going it's not fast enough for so many patients who are suffering from these diseases so thanks very much for having me on it's been a real pleasure uh reconnecting over these many important tops X I really appreciate the chance to talk with you well delighted to do it and looking forward to doing it again you're an amazing colleague friend clinician and now public health educator thank you thank you for joining me for today's discussion all about I and vision health with Dr Jeffrey Goldberg I hope you enjoyed the discussion as much as I did if you're learning from Andor enjoying this podcast please subscribe to our YouTube channel that's a terrific zeroc cost way to support us in addition please subscribe to the podcast on Spotify and apple and on both Spotify and apple you can leave us up to a fstar review please also check out the sponsors mentioned at the beginning and throughout today's episode that's the best way to support this podcast in addition if you have questions for me or comments about the podcast or you'd like to suggest a guest that I feature on the hubman Lab podcast please put those in the comment section on YouTube I do read all the comments during today's discussion and on many previous episodes of The huberman Lab podcast we discuss supplements while supplements aren't necessary for everybody many people derive tremendous benefit from them for things like improving sleep for hormone support and for improving Focus the uberman Lab podcast is partnered with momentous supplements if you'd like to see the supplements discussed on the hubman Lab podcast you can go to live momentous spelled o us so live mous.com huberman if you're not already following me on social media it is huberman lab on Instagram Twitter Facebook and Linkedin in all those places I discuss science and science related tools some of which overlap with the content of the hubman Lab podcast but much of which is distinct from the content on the huberman Lab podcast so again it's hubman lab on all social media platforms if you haven't 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