Dr. Julie Furlan joined hosts Shannon O’Kelley, Physical Therapist and President of Integrated Rehabilitation Group, and Maury Eskenazi, radio personality from Fox Sports radio on Health Matters radio, KRKO 1380am, with thanks to Integrated Rehabilitation Group physical and hand therapy. She talked about macular degeneration.
Read the transcript of Dr. Furlan's talk on macular degeneration or listen here
Health Matters: Absolutely. We want to welcome a first time guest with us. We are always excited to have new doctors come on. It's Dr. Julie Furlan, ophthalmologist, and vitreoretinal specialist and surgeon from The Everett Clinic. We're gonna talk about macular degeneration, but, first of all, what's the difference between an optometrist and an ophthalmologist?
Dr. Furlan: An optometrist is trained differently than an ophthalmologist. An ophthalmologist goes through four years of medical school, and then you have to do four years of an ophthalmology residency training, and that's where you learn to do all of the ophthalmic procedures, surgeries like cataract removal.
Health Matters: So, I mean, you're more from the surgical side than an optometrist, which is the diagnostic side. And, interesting, you were talking off the air about a fellowship that you did an extra two years in some specialization.
Dr. Furlan: Right. So, after you complete your four years of ophthalmology residency training, if you want to go on to do something subspecialty, like vitreoretinal surgery, you have to do an additional fellowship training, and retinal surgery is a longer one. Most of the eye subspecialities are only a year, like glaucoma. Oculoplastics is a two year and retinal surgery is another two year one, so in total it takes 10 years after you graduate from college to become a retinal surgeon.
Health Matters: What made you want to get into this part of medicine?
Dr. Furlan: I always knew I was interested in the eyeball, and it’s a really fascinating part of the body.
Health Matters: It's incredibly amazing. It's pretty complex, the eyeball. Tell us how the eyes work.
Dr. Furlan: So, starting from the front, if you were to theoretically reach up and touch your eye you would hit your cornea, which is a clear structure. There are no blood vessels going through it. That's why light penetrates well. Actually two-thirds of the light rays that enter our eyes are focused by our cornea. That's why LASIK surgery is so effective, because it is actually reshaping your cornea so it bends light more effectively, focuses it more precisely on the back or your eye, the retina. And then, going back further inside in the eye you hit your iris, and then right behind that is your lens, and that's what becomes cloudy over the years. We all get cataracts to some degree, and that's what that means, is the lens just becomes progressively larger throughout our lives and it becomes progressively yellower in most people's cases, and firmer. It loses its plasticity, its ability to change your focal point. That's why most of us can focus way out there on a mountain on a nice sunny day and then focus up here at our hand when we are 20 years old, and then, by the time we hit around 45 we kind of lose that ability.
Dr. Furlan: Then, going a little further back, you end up in the vitreous cavity, which is mostly water. It allows light rays to penetrate easily to focus on the retina, which is the very back part of the eyeball, and it's similar to the film in the old fashion-types of cameras. It's like a black, pinhole black box effect where the world that you see is actually projected through the pinhole, which is your pupil, onto your retina in an inverted image of the world.
Health Matters: And, the retina is pretty amazing because it deciphers all this light that's hittin it, and that's where the image comes from. And, you do surgery on the retina. How do you do that? How do you do surgery on a retina?
Dr. Furlan: With a really high-powered microscope.
Health Matters: Okay. So, tell us where macular degeneration comes in?
Dr. Furlan: Macular degeneration is what we call a medical condition. It's not a surgical condition like a retinal detachment where you have to physically put the retina back into position to make it work better. Macular degeneration is a functional problem of the retina where the cells undergo a slow degenerative process and they lose their ability to function. Health Matters: What's causing the loss of functionality of the retinal cells? Circulation, is it lack of? Is it just age, worn out?
Dr. Furlan: It's actually a whole bunch of different factors and it's a huge area of active research going on in this country. There are a whole lot of people who are affected by macular degeneration.
Dr. Furlan: It's the leading cause of blindness in people over the age of 65, not just in this country but in all developed countries around the world, and people who are over the age of 80, about one-third of them will have early or some other stage of macular degeneration. It's very common.
Health Matters: And, are you gonna to notice this loss of acuity or vision acuity at the daytime, nighttime? Are there distances you notice, and who gets it?
Dr. Furlan: There are a lot of risk factors. The primary one seems to be family history. About a third of patients who have macular degeneration come with a family history of somebody else they know of in their close family is either suffering from it or had it. There are nutritional factors. There's a lot of evidence that eating a diet that's rich in green leafy vegetables, high in antioxidants, that helps.
Health Matters: Carrots?
Dr. Furlan: Carrots are good. (Laugh)
Dr. Furlan: The biggest risk factor apart from your own genetic predisposition seems to be smoking.
Health Matters: And, are people showing up to your office because they are having problems driving, reading, just functioning in general?
Dr. Furlan: Well, there are two types of macular degeneration, two broad categories. The most common one, 90% of people have the dry form of macular degeneration. That means is the cells are just slowly degenerating back there in the central retina where all the light rays get focused, and oftentimes they're asymptomatic, they don't have any symptoms, they don't know that there is something going on, and so that's why it's so important to get in to have your eyes checked because a lot of times people don't even know they have this until they go in to get their glasses checked, and their optometrist looks back in their eyes and says, "Hey, you know there's something that's not right back here. I think you might have macular degeneration. Go see your ophthalmologist." Then, we do a series of tests and confirm that, yes, in fact, that is what's going on.
Health Matters: Let's talk about that test the optometrist does. I mean, is he or she looking through your eye and can tell via that scope that they have that there's something wrong with the retina? What, what do they see?
Dr. Furlan: The early stages of macular degeneration are actually little yellow spots in the central retina, and those are called drusen. There are different stages of macular degeneration and that has to do with how big are these drusen? How many of them are there? What's the distribution? And then, there's kind of a second tier of the dry form where it's not just drusen anymore, it's actually, atrophy. This is cellular atrophy where the cells are just dead, they're just gone, they're missing. That's called geographic atrophy and that can cause symptoms. If you have an area where you're missing cells in your central retina you will oftentimes notice there's just a big blank spot everywhere you're trying to look. If you're trying to focus on the words on the page, you're trying to recognize somebody's face, and there's just a big blurring spot every time, everywhere you're trying to look.
Dr. Furlan: That usually catches people's attention. They come in and get diagnosed for that.
Health Matters: What about the wet form?
Dr. Furlan: The wet side, if you think about the structure of the retina. The retina is kind of like phyllo dough. There is a bunch of different layers that make up the structure of the retina. The very floor layer is called the retinal epithelium, retinal pigment epithelium, and that's the layer that's affected by macular degeneration primarily, and when you start getting breakdown of that layer there's little holes that form within that layer. What happens, what can happen in the wet form of macular degeneration is the blood vessel layer that lives just underneath our retina, it's called the choroid, starts to get misdirected. It starts to grow little abnormal tufts of blood vessels up into the layers of the retina where there shouldn't be blood vessels.
Dr. Furlan: That's when real trouble breaks loose. It starts bleeding, there's fluid pockets that develop within the retina, and that's what the wet term actually means.
Health Matters: And, the same kind of symptoms? I mean, loss of visual acuity or field disruption? Is this the more serious version.
Dr. Furlan: This is the more serious version. This is 10% of people with macular degeneration have the wet form, and those people usually say, "I just woke up today and saw this huge blank spot in my field of vision, and it's really big and dark…
Health Matters: ...kind of a sudden onset, then?
Dr. Furlan: Yes, it's very dramatic and causes an abrupt decline in vision. But, we have good treatments for that kind. This is new as of about 10 years ago. Ten years ago, there weren't very effective treatments for this, so we're really lucky to be living and working in an era where we've got great medicines for this.
Health Matters: So, let's talk about treatment for both kinds.
Dr. Furlan: For the dry kind, right now we don't have any specific treatments for this other than vitamins — only for people with moderate or severe macular degeneration, they have some benefit.
Health Matters: The wet type, the 10% of those people who get the wet type, that's a surgical intervention, it sounds like.
Dr. Furlan: Minor procedures. There are injections that we do of medication directly into the eye, which always makes people panic a little bit, and it sounds like the last thing any, anybody would ever want to have done, but everybody tells me the idea of it is actually worse than the actual thing.
Health Matters: Is, as far as what you see when you have macular degeneration, is it completely blindness, or is it, like you said, just pieces of it missing?
Dr. Furlan: Macular degeneration does not affect the sides of your retina, so it spares your side vision, so it never eliminates your ability to walk around independently and avoid bumping into walls, that kind of thing, but it does pose a threat to your central vision, everywhere you're trying to focus, face recognition, reading, that kind of thing.
Health Matters: So, those retinal cells, if they die or atrophy, like you're describing, they don't, you can't bring them back? I mean, that's what you have and you don't transplant those, or bring ‘em back?
Dr. Furlan: Huge area of research. We're all waiting with our fingers and toes crossed…for this next breakthrough. How do we replace cells that have been lost or damaged?
Health Matters: Very interesting. Thanks so much for coming on with us everetclinic.com is where you can go and probably get a hold of you and make an appointment, right? everettclinic.com.