To See or Not to See

GUEST: Robert Coles
VTR:8/1/84

I’m Richard Heffner, your host on The Open Mind. And I admit that, as I get older and older still, to a growing awareness of the very natural impairment of senses that perhaps younger people assume will remain intact forever. Oh, I know better; I’m older. I know, for instance, that sound and sight, and memory too, of course, are not as strong or firm or vigorous as once they were. But how could it be different? We weren’t meant to last forever. The machinery does slow down, does need repair at times, doesn’t usually serve as well now as then. And no doubt it would be salutary for us to deal with that fact. I know that I must. I hear less well, see more dimly. And I suspect that it is more and more limited vision that first signals us of the larger limitations of the flesh. So today I’ve invited to The Open Mind an internationally distinguished ophthalmologist, Dr. Robert S. Coles, Director of Ophthalmology at Lenox Hill Hospital, and Associate Clinical Professor at Mount Sinai Medical School, to discuss with us the problems and the opportunities related to impaired vision. Now, I know that, though a virtuoso surgeon, Dr. Coles is interested in wellness, not just illness. And I want to ask him how true it is that there are none so blind as who don’t see, and don’t do what can be done to help the vision-impaired.

Dr. Coles, what do you have to say about that?

Coles: Thank you, Dick. Well, I think ophthalmologists as a group in the medical confraternity do see, and they do have good idea of what’s necessary to curb the ravages of the loss of sight. It’s estimated that in this country, oh, approximately 500,000 people are legally blind. And each year that number increases by about 50,000. The definition of legal blindness is something which needs a little clarification, I think. Legal blindness is somebody who has vision of 20/200. And translated into ordinary terms, that would mean that a patient who sees something at 200 feet, whereas you could see it at 20 feet. So the difference becomes enormous. These people subtend an angle of only 20 degrees from the point of fixation. So that they are perfectly capable of functioning to a certain degree; but legally they are blind.

Heffner: But you’re talking about legal blindness. And it seems to me, it seems to me as I get older and older still, as I said, and there is that dimness, and so many of my friends find it not just hard to hear, but a little bit more difficult to see, that we’re all prone to, we’re all liable to, if not failing eyesight, then dimming eyesight. And how do you deal with a population that is getting older and older by far? And I’m sure that your patient population must be older now than when you began your practice.

Coles: Yes, that’s true. Actually, I would like to point out to you that this increasing loss of vision begins, the first sign that you have, Richard, that you’re getting older. The first sign of the fact that you’ve suddenly reached middle age is when you can’t read the newsprint anymore, you have to put on a pair of glasses in order to see. It’s a terrible shock. I mean, you push it away and you don’t want to admit that you see it. But that’s the first one of the senses to really, really awaken you to the fact, as you mentioned, that you’re getting older and that there isn’t too much you can do about it other than to accept it and get a pair of glasses. Sure, you can put it off for a little while by pushing the paper away and by getting glasses and increasing the illumination. But basically, as we get older, the population, as we get older, becomes heir to a whole group of diseases which the young are not heir to: glaucoma, cataracts, micro degeneration, optic nerve atrophy, and other distinct entities which involve the eye in particular, and also systemic disease. Because the eye really not only is the mirror of the soul, but it’s also the mirror of the body.

Heffner: What do you mean by that? I know that it is the mirror of the soul. But how do you mean…

Coles: Well, as far as the body is concerned, body illness is reflected in the eye. I daresay that there isn’t a disease that I can think – and I’m an old internist before I became an ophthalmologist – I can’t think of a disease, Dick, that doesn’t have some manifestations in the eye. And I can look into a person’s eye and I can tell if they have hypertension, I can tell if they have arteriosclerosis, I can sometimes tell if they have leukemia, I can sometimes tell if they have cardiac disease, and so forth down the line. In other words, the eye is an integral part of the body. And it’s fascinating to think of what a wonderful organ this eye is. I mean, because of all of our sense – and we have five senses – the one which is the smallest sends the most number of sensory fibers to the brain. Exactly one-half of all the sensory fibers that go to the brain and give us our impressions come from the eye. The other half come from taste, come from touch, come from smell and come from hearing.

Heffner: From what you say, then, I gather that I wasn’t misspeaking when, in terms of my own experience and that of my friends, that I assume that that’s where it all begins, when you begin to be aware of the ravages of age is when you begin to know that your eyesight is – I won’t say failing – but dimming.

Coles: Well, I think we have something in common. Because when it first struck me, I pretended it didn’t exist. I went around and changed all the bulbs in my apartment from 60 to 100 watts so that I could see more easily. And that’s one way of delaying it a little bit. But then I started to ponder, as I reluctantly prescribed the first pair of glasses for myself and surreptitiously used them in dark areas so people wouldn’t notice, I began to ponder: why did this happen? What causes the change in the eye? And actually, what it is, it’s a loss of elasticity of the lens, which doesn’t change like the bellows of a camera to focus the rays of light on the retina as it does ordinarily. And I tried to figure out why the good lord, in his infinite wisdom, afflicted us with this. And then I realized, as you get older, Richard – and I don’t want to insult you – you begin to develop certain wrinkles and certain freckles and certain little old-age changes around your face, as I do, and as everybody else does.

Heffner: You’re not talking about me, are you?

Coles: No, no. All of us. You, of course, aren’t involved. And what happens is, the closer we get to somebody, the more blurred they are. So the good lord made it so that as we grow older, our partner, as we approach them, becomes more beautiful and more clear because they become more blurred.

Heffner: Are you just…

Coles: So there was a reason for making presbyopia – because that’s what we call it – making us unable to see things up close.

Heffner: Are you joshing? Do you really believe that it is a mechanism by which we can cope better with the ravages of age?

Coles: I think, for some people, definitely.

Heffner: That we see less of what there is to see?

Coles: Less of what we don’t want to see.

Heffner: Well, I’ve thought often, when I realize that I’m not hearing as well, that maybe I don’t want to hear what there is to hear. When we begin to experience this phenomenon, however, whether it is god’s will to protect us from what there is to see as we come closer to those who are aging with us, is there a kind of reluctance on the part of many people, most people, to deal with the phenomenon of looking for those aids, for those auxiliary means of fostering one’s eyesight?

Coles: I will only reiterate my own experience. There sure is. On my part, and certainly on the part of women, more than men, I think. They just don’t like the idea of prescribing, having glasses prescribed for them. They just don’t want to need that crutch. And the same thing as the nearsighted child in class doesn’t want to wear the crutch of wearing glasses, because it marks him out, it distinguishes him. And the same thing when you go into a restaurant and somebody has to fumble around in their purse or reach into their breast pocket to get their glasses to read the menu. It’s an admission that they’ve reached a certain age. And they may look ten years younger, but when they reach out for their glasses, that admission is right there. But, you know, I think that the glasses, the need for glasses is really the least important of all the factors. Because once you can make somebody see with glasses, you’ve already conquered a certain degree of blindness. You’ve helped that person. When I started out in practice, I got tremendous satisfaction of taking somebody who came in who was nearsighted, giving them a pair of glasses or giving them a pair of contact lenses, and enabling them to go from 20/200 vision to 20/20 vision. I mean, they’re excited, I was excited and they were pleased. It was a sense of achievement. And there is nothing more important in this world of ours today than sight. I think sight, I mean, television, certainly, everybody sits, this medium that we’re on tonight.

Heffner: I don’t know that that’s a recommendation, Dr. Coles.

Coles: (laughter)

Heffner: But I wondered about that. The thought of glasses being a crutch. The thought, I know, occurs to some people that once you start down that slippery slope, there’s no stopping. If glasses are prescribed early on, that if you start using them, you’re going to use more and more desperate mechanisms of coping as you go along.

Coles: (laughter)

Heffner: Is there anything to that?

Coles: Let me start with the plain, simple, nearsighted child, and then work my way up to the older person, okay? The nearsighted child is genetically predetermined. And people say that he became nearsighted because he read too much, he read in the dark light, watched too much television. Absolutely untrue. Everything, like all of our illness, everything about our life is predetermined. Histocompatibility antigens, which is the latest thing in medicine, determine what disease we’re going to be prey to. Chromosomes determine whether we’re going to have a long nose or a long eye. And if we have a long eye, we’re going to be nearsighted and we’re going to require that crutch. And it’s very interesting , when you think of myopia, myopia is something which is interesting in terms of the fact that 15 to 20 percent of the population in the Western world are myopic. Approximately 50 percent are farsighted, or hyperopic. If you go over to China and go to Japan, 50 percent of the population is myopic. If you go to the Semitic races, if you go to the Egyptians and the Jews, a much higher incidence of myopia is present.

Heffner: Genetically determined?

Coles: And we feel what this represents, in a way, is a survival of the fittest, because these civilizations are older civilizations. And in the younger, new civilizations where hunting and surviving and having good vision, namely being farsighted is more important than being nearsighted, you don’t have that many farsighted…nearsighted people. Whereas in an older civilization like the Chinese and the Japanese and the Semitic races and the Egyptian where, which is the cradle of civilization, around the Mediterranean, there you have a civilization which has enabled the myope to develop and flourish and genetically to express itself.

Heffner: Of course, when you talk about genetic basis for sightedness of one kind or another, I obviously need to ask you whether you can determine now whether ophthalmologists, whether the scientists can determine now from the genes present at birth what the eye or vision history of a person will be?

Coles: Do you mean in terms of their background? Yes, it’s to a large extent determined by exactly…myopia tends to go in families. And you have myopic parents – it’s a recessive gene – but if you get two parents who are myopic and get together, or you have one parent who is but one who has the recessive gene somewhere on his chromosomes, and gets together with the other parent with the recessive gene, it will come out as myopia.

Heffner: Now, do people – you talked about the difficulty, you made a sexist remark. Now, it was a scientific remark because you were digging back to your scientific experience that women in particular are concerned about the mechanisms, glasses, for instance, to restore better vision or to improve their vision – do you find an increasing willingness these days to take the steps that are necessary to increase sightedness? The wonderful story about Theodore Roosevelt as a boy, when he was considered weak and puny and incapable of doing many things, and we just didn’t know that he couldn’t see, that he had badly impaired vision.

Coles: Uh hum.

Heffner: When he got glasses, he became president of the United States.

Coles: The president of the United States.

Heffner: But the question is – and I’m very serious about that – do you find a greater willingness now, do you find a nation that is willing to do what needs to be done to bring its vision, and I’m not talking politically…

Coles: I think this is…no, no. I think that this is a very valid point. I think people are now much more aware of all the frailties. I mean, there’s been much more communication, much more publicity about all of this.

Heffner: But are they willing to take the steps that are needed?

Coles: Yes. It varies. It’s hard to tell a lot. Sure, most people are. Bu the difference of seeing and not seeing is terribly important. We live by sight. Sight is our most important sense, as I mentioned before. Half the fibers that go to our brain come from, emanate from the eye. And therefore, people, if they’re deprived of their sight, they’re missing something terribly. And they really want to see. So I find that most people do want to see. Now, the big change that’s occurred in the past decade or so, the past 15 years, is contact lenses. And people can get away with not expressing to the world at large the fact that they are wearing glasses, because they’re wearing contact lenses, which enable them to see very well. However, if they’re past a certain age, over the contact lenses they’re going to have to put on their reading glasses. There’s no way of getting around that. There are some bifocal contact lenses, but they’re not very effective, they’re not very important.

Heffner: And in your own field, surgery, do you feel that great strides have been made there to impair, to remedy the impairment of vision?

Coles: Incredible strides. When I think of the revolution which has occurred in my field and in all fields of medicine, I mean, it’s very exciting to be a physician. It’s very exciting to see the good that you can do and the repair that you can do with the ravages. For example, one of the leading causes of blindness in the United States is cataracts. Cataracts account for approximately 15% of all blindness in the United States. But it’s remediable. You can cure cataracts. Now, in the good old days, you take out the cataracts, and then the patient would be left with coke-bottle glasses, and they flounder around and they couldn’t manage because they had a tremendous amount of visual distortion because of the thickness of the lens which they had to place in front of their eye. And they weren’t happy. Then came contact lenses. Many people could not tolerate them. The older people couldn’t put the contact lens in their eyes because they had trembling hands, they had arthritic hands. They couldn’t manage. And then the greatest invention was the intraocular lens implant. And could I digress for a second to give you the origin of the intraocular lens implant? Because it’s fascinating.

Heffner: Sure.

Coles: It goes back once again to those wonderful words of Winston Churchill: “Never have so many people owed so much to so few.” And he was talking about, as you remember, the pilots of the Spitfires and Hurricanes who won the Battle of Britain. Well, these pilots in their Lucite canopies, frequently were shot at and shelled, and the canopies exploded, and fragments went into the eye. And the flight surgeons who treated them found that when they would dig deep into the eye – don’t forget, in those days our surgical techniques were much more primitive than they are today – they lost the eyes. The eyes didn’t survive the insult of the trauma of surgery. And then they noticed that, by god, the Lucite was inter. It didn’t cause any reaction in the eye. And those eyes did much better if they left that little piece of canopy that exploded into the eye, and the patient would, the flight commander or the pilot would have better vision than if they attempted to remove it. So much for the Battle of Britain.

In 1945, a very illustrious man called Harold Ridley was operating at Moorefield Hospital. And as he took out the cataract on the patient on whom he was operating, the resident who was standing next to him said, “Wouldn’t it be wonderful, Dr. Ridley, if you could replace that lens with something which would enable the patient to see without wearing those terrible, god-awful glasses?” And, you know, I think that chance favors a prepared mind. Most people are afraid to see into the Petri dish with the penicillin mold on it that Alexander Fleming saw. They would have said “Oh damn,” and thrown it away. But he recognized what it was. Well, Harold Ridley felt the same way as Fleming. He went home and thought about what that resident had said, and he thought of his wartime experiences. And he fashioned the first intraocular lens implants that went into the posterior chamber of the eye. And he put in 100 of them. Some of them didn’t do so well, because they were crude and the optics were bad and the lenses were too heavy. But it was a start. And this was an incredible revolution. These patients could see without having to wear glasses, without having to wear contact lenses. The history was a stormy one, because the first lenses that were implanted were too heavy. They were crude. They weren’t polished. They weren’t well done. And it fell into disrepute because the first hundred patients that he did, quite a few did very poorly. They really didn’t do. And then a Dutchman called Dinkhorst and another Dutchman called Waust seized upon a new type of implant, and completely forced – and also an Englishman called Choice – forced it back into the limelight of ophthalmology. And then the Americans stepped in, as the Americans always do, with a tremendous élan, with a tremendous push forward. And at this stage of the game we’re now on our third or fourth generation of intraocular lens implant, and they are fantastic. I mean, I have now placed them into the eyes of a 26-year old person, for I have that much confidence in their safety.

Heffner: But you know, you talk with great enthusiasm about this surgical procedure. And I’m sure that all, any of us who know people who have benefitted from the procedure can cheer you on. But I also had come across this very interesting article in The New England Journal of Medicine. “Sounding Board: Coping with Blindness.” And for all of your enthusiasm about surgery, and for all of the perfections that have been brought about in the procedures, the doctor who wrote this, who is – and you know the piece – is close to blindness or blind himself, feels that people in your field are not sufficiently ready to point out all of the non-drastic techniques that can be pointed to, the steps that can be taken to, not to remedy, not to replace, but to ameliorate failing vision. Is that a fair commentary on his part?

Coles: Not completely. Really not completely. First of all, I’d like to point out that this physician who wrote this article, who is a very eminent physician, had one of the commonest causes of blindness amongst the elderly. Twenty-five percent of all blindness in the United States – by “blindness,” I mean diminished vision, inability to really read, perhaps – is due to hardening of the arteries in the back of the eyes. Senile macular degeneration is the medical term. And this is a condition which, as our population ages, and Dr. Carl Cupfer of the National Institutes of Health estimates that by the year 2000 there will be perhaps a 200 percent increase in the number of people above the age of 85. And that is going to be exponential growth of blind people, or people who are visually terribly handicapped. And so we, as scientists, and our colleagues, our immunologists and our Ph.D.s and our doctors have to find some cure to hardening of the arteries. We have to find something that’s going to prevent it rather than do remedial. I mean, prevention, to me, is much more important. Remedial factors are very important. And I would say to everybody who is listening to this program, if they do have hardening of the arteries, if they do have what you described in that article, then it’s incumbent upon them, if their ophthalmologist hasn’t done the very best, to get them off to somebody who specializes in low-vision aids, and there are so many low-vision aids that can help these people. Not only are there telescopes and microscopes and there are television sets where you can put the piece of paper, reading matter in the bottom of the television set, and then you can use a little dial and you magnify the image, and they can really read. Slowly and better, but they can read. There are talking books which are available. There are a whole variety of aids which are…these patients are never blind totally. They can always get around. They can dress themselves. They can go from room to room. They can even travel. Their main problem comes… and for an intellectual and brilliant man such as the man who wrote this editorial, it’s a terrible loss not to be able to read. It’s a terrible thing. So that everything should be done.. I think that most of our confreres unfortunately, as he points out and as you reemphasize, make the diagnosis and they feel that the responsibility ends there. This is not the way it is with all physicians, all ophthalmologists. Because I think the continuing care of the patient doesn’t stop once you’ve made the diagnosis.

Heffner: but isn’t this part and parcel of a criticism that is made not of ophthalmologists – and I use the word ‘criticism’ in a very gentle sense; not a criticism, “these awful people” but an awareness of the nature of contemporary medicine – that there really isn’t the time, that there really isn’t’ the time for the physician to help those who are, who could use help, rather than looking for prevention and rather than looking for a drastic cure, or rather than surgery, their handling, the management of illness?

Coles: I think that’s most important Richard. Patients come to me. Every time a patient comes to a physician, no matter who he is, he’s frightened. That may take the form of hostility, withdrawn, quiet, taciturn individuals when you interview them. The minute you’ve finished the examination and you say, “You don’t have glaucoma, you don’t have cataracts, you don’t have macular degeneration,” their whole face lights up and they’re relaxed because they’re frightened and they’re nervous. And the same thing, I think that once you’ve made a diagnosis such as this gentleman had, then it’s incumbent upon you to give him all the help and all the succor and to go out of your way to help him as much as possible, to direct him. And I do feel it is the role of the ophthalmologist to take somebody who has macular degeneration. I know, there are a whole group of ophthalmologists, a whole group of them, who specialize in what are known as low-vision aids. I spoke to one of them yesterday who spent three hours with one patient trying to help her. He took her to The Lighthouse from his office because they had certain other devices which he didn’t have in his office, to try to help her. And that to me is a man who is trying very hard. Now some of us who are too busy or interested in different aspects of ophthalmology perhaps won’t do that. But there’s a growing body of physicians, not only in ophthalmology, but in everything, in all fields of medicine, who are going to be interested in caring for the patient. Because I think the most important thing is for the patient to feel that you care and that you’re doing your very, very best. Let me just go on.

Heffner: Go ahead.

Coles: One other thing that I’d like to say is that patients who benefit from this see better and do better that they know that you are helping them. There is a certain amount of confidence. There’s transference. And that’s the whole ballgame. If you don’t get transference with your patients, then you’ve lost a great deal.

Heffner: All right. Let’s take the statements you have made – and we just have a couple of minutes left – and let me ask you whether you are satisfied that not just the medical establishment but the medical establishment in medical schools, whether we are training our physicians sufficiently, adequately, along the lines that you’ve just suggested? Training people who will deal with patients in that patient way?

Coles: There is absolutely yes answer. Because first of all, you have to realize that we’re developing a whole glut of doctors. There are more doctors being turned out in the United States now, and it’s projected that in 1990 we’re going to have a glut of doctors. So the doctors obviously…

Heffner: Have I

Coles: They have to elect to go into other areas. There are whole new specialties: geriatric medicine, community medicine, family practice. There’s a revival of that type of medicine that we used to see in those wonderful Rockwell Kent drawings where the doctor would be holding the pulse of the patient. Sure, the patient felt much better as he died. The patient today may not feel so good if the doctor cures him, but he is being cured. But in addition to curing the patient, there is a whole new sub specialization that’s growing up in which emphasis is going to spent and paid to giving that patient the feeling that he is being followed through all phases of the illness, not just the diagnosis of his disease.

Heffner: Are you convinced the medical schools are dealing sufficiently with this promise?

Coles: I think some more than others. I think it varies. Any school, for example, my school, Mount Sinai Hospital, has just established a department of geriatric medicine. And this is a whole new ballgame.

Heffner: Getting…

Coles: I mean, no medical school ever had a department of geriatric medicine.

Heffner: Getting ready for me. Thanks so much for joining me today, Dr. Coles. And thanks, too, to you in the audience. I hope you’ll join me again next time. Meanwhile, as another old friend used to say, “Good night and good luck.”