Goethe once wrote: “The eye was the organ, par excellence, through which I apprehended the world.” Professor Auffarth, you know all too well how important eyes are to the way we perceive the world – you’ve been involved in the field of ophthalmology for 30 years. What do you consider the most important milestones in this field during this time?
There’s no other way to describe the developments in ophthalmology over the last 30 years than dynamic. It’s nothing short of breathtaking. In the 1980s, there were around 200,000 cataract operations in Germany. This number has now quadrupled. Also, lots of the manual techniques that were used in those days are now completely different, sometimes controlled by imaging. Ultrasound is used now, or so-called femto-second lasers. There have also been dramatic changes in the type of implants and biomaterials used. Until 10 or 15 years ago, it was quite normal to use single-vision artificial lenses, but now a whole gamut of artificial lenses have been developed, making it possible to make all sorts of corrections. Laser technology has expanded rapidly in ophthalmology in recent years.
Other milestones would include the significant changes made in transplantation surgery involving the cornea. Until ten years ago, it was only possible to transplant the entire cornea. Now individual layers in the eye can be operated on, right down to layers of individual cells (endothelial cell transplantation). The first attempts at making artificial corneas are underway in the lab and some have already made it into clinical studies. In the field of glaucoma surgery, which for a long time had reached an impasse, more than 15 new surgical procedures and implants have been developed in the last five years alone. This is referred to as micro-invasive glaucoma surgery (MIGS) and it significantly expands the options for treating the condition. Important progress has also been made with the treatment of so-called age-related macular degeneration by administering special medicines in the vitreous body. Of course it should be pointed out that this will have a significant impact on the health system due to the high cost of such medicines.
At your Steinbeis Research Center, the International Vision Correction Research Centre (IVCRC), which you set up seven years ago, one of the areas you look at is special lenses. There’s been tremendous progress in this field in recent years, such that artificial lens implants are now a routine intervention. Despite this, you’re still conducting research in this area. What developments do you expect in the future?
It’s certainly true to say that cataract operations are now highly standardized and the most common operation carried out in medicine. Around 800,000 operations are carried out in Germany. The practice of implanting artificial lenses has practically been routine for around 20 years. The most commonly used lens for most cataract patients is the standard monofocal lens. Following the introduction of aspheric lenses, the quality of the image provided by this lens has now improved significantly. But it’s worth mentioning that these aspheric lenses are constantly becoming “smarter.” There have also been some major improvements in multifocal lenses in recent years: trifocal lenses can provide clear vision in different areas.
It’s also important that the complications that were associated with the early models, such as poor contrast or a strong sensitivity to glare, have mainly been alleviated or even prevented. The last hurdle to overcome is the development of accommodative lenses. These are lenses that can be set to adjust to different distances in the way the human lens can in younger years. There are a variety of concepts in this area and clinical studies are also already underway, which our research center is also involved in – we’re seeing some promising new developments in this area.
Some of the new developments our Steinbeis Center is involved in include projects with patients with age-related macular degeneration – special lenses are being used with the corresponding magnification so that, despite their poor eyesight, they can play an active role in society again and enjoy activities such as reading again.
A lot has also been happening in medical technology recently. For example, the development of femto-second lasers. What can be achieved with these new techniques? What are the advantages, but also the disadvantages?
A femto-second laser can cut tissue at an extremely high velocity with equally extreme accuracy. We’ve been working in this area for over 10 years, including with local firms from Heidelberg who have been doing pioneering work in femto-second laser technology. The first work with this technology revolved around the cornea in the eye. It became possible to carry out refractive procedures (femto LASIK) and no longer make incisions with a blade but with a femto-second laser instead, creating so-called LASIK flaps. Specialists from Heidelberg were also involved in development work and carrying out cornea transplants using femto lasers. They’ve also recently started making cataract incisions using femto-second lasers. The advantage with these new cataract surgery techniques is that there’s significantly more standardization and repeatability of the incisions during the operation.
Our society is aging, resulting in more and more people being affected by age-related eye disorders. What challenges does this pose for technology in the field of medicine?
We’re all aware of the demographic developments in the West, especially in Germany. The proportion of patients over the age of 65 will rise dramatically in the years and decades to come. One area of medicine particularly closely affected by this is ophthalmology. That’s because, in comparison to lots of other fields, it sees a relatively high number of age-related conditions. At a certain age, some diseases are no longer the exception but the rule. Then there’s the somewhat banal fact that each one of us has two eyes, so at one time or another, operations or treatment of certain conditions become necessary on both eyes. The big problem in terms of health policy will be how to treat age-related macular degeneration. More and more pharmacological substances are being developed providing us with the means to intervene with treatment. At the moment it looks like the number of trained eye specialists will not be able to keep pace with the demographic changes. I believe that overall this will be a colossal problem for the health care system.
Casting your thoughts to the future for a moment, what will it be like for ophthalmologists? What do you believe will be the focus of research and medical care?
It’s always difficult to predict the future. There’s always a surprise in store - even if you have an intimate knowledge of internal processes. The way things seem to be developing right now, there’ll be further progress in the field of laser and lens technology. In particular, safety is improving continually. There will also be much more momentum with diseases related to glaucoma and cornea transplants, and long-term studies will show which implants and medicines will move to the fore in the long term.
In terms of fundamental research into age-related macular degeneration and related retina disease, new possibilities will emerge, not just for imaging but also for treatment. The sheer number of patients will increasingly become a real headache when it comes to the funding of treatment options.
More and more research is being conducted into stem cells, especially at a fundamental level looking into the treatment of eye conditions. The genetic treatment of known genetic defects, especially hereditary retina conditions, is making tremendous progress and the first clinical studies have already taken place in this area.
Prof. Dr. med. Gerd Auffarth is director of the Steinbeis Research Center of International Vision Correction Research, which is based at the University of Heidelberg. Research at the center focuses on the front part of the eye. The Steinbeis experts investigate new and established technologies, as well as the treatment of methods cataracts, refractive surgery, cornea surgery, pharmacology and diagnostic options. In 2009, the center was honored with the Transfer Award of the Steinbeis Foundation (the Löhn Award).
Professor Dr. med. Gerd Auffarth
Steinbeis Research Center International Vision Correction Research Centre (IVCRC) (Heidelberg)
su1106@stw.de