Retina Specialist on Macular Degeneration and Other Conditions

Hadley Presents

Retina Specialist on Macular Degeneration and Other Conditions

Presented by Ricky Enger

Ricky Enger: Welcome to Hadley Presents. I'm your host, Ricky Enger, inviting you to sit back, relax, and enjoy a conversation with the experts. In this episode, Hadley's chief program officer, Ed Haines, interviews Dr. Tim Murray, member of the American Society of Retinal Specialists. Thank you both so much for joining us. Welcome to the show.

Ed Haines: Thanks, Ricky.

Dr. Tim Murray: Thanks, Ricky.

Ricky Enger: I'm really excited to have you both here today because the retina is actually a pretty cool part of the eye, and I'm looking forward to learning a lot about it. But before we dive into that, I'd like to learn a bit about each of you. So why don't we just go through and have each of you tell a little bit about who you are and what you do. So, Ed, let's start with you.

Ed Haines: Well, thanks Ricky. Well, I am the chief program officer at Hadley, and I've worked at Hadley full-time for about three years, part-time for a number of years, but the majority of my career has been spent working with older adults with age-related vision loss.

Ricky Enger: So great to have you here and to have you sort of interviewing from that experience. Dr. Murray, I'd like to know a bit about you. So just tell us a little about yourself. And I'm always curious how people get into the careers that they ultimately have, what's the path that leads them to where they are. So, a bit about you, and then just how you decided to become a retinal specialist.

Dr. Tim Murray: So, it's really good to be here and join both of you. I practice retina in Miami, Florida. I was at the Bascom Palmer Eye Institute as a professor for 20 years, and I went into private practice almost 10 years ago now. And I have a unique practice where I take care of retina specialty problems, but also I take care of cancers of the eye, which is called ocular oncology.

So, it's kind of exciting to have a unique practice. I'm the immediate past president of the American Society of Retina Specialists and I'm the current president of our foundation. And my path to medicine was interesting. I have been interested in medicine since I was little. I went to Johns Hopkins for my undergraduate and medical degree. And when I was there, it became very interesting and clear to me that I loved to take care of patients that were young patients at early, almost premature infants, all the way up to much older patients in their nineties and hundreds. And that I found that retina was a specialty that would allow me to do that. It's very visually focused, as you've said, the technology is incredible, and it's probably the most precise microsurgical field that exists today. So, I think I made a really good choice. I wouldn't want to practice any other type of medicine. I think that retina is incredible, and we'll have a little bit of time to talk about it today.

Ricky Enger: That's very cool. I love hearing your passion for the subject and I think that's going to make this episode particularly interesting, just hearing you talk about what you love to do most. So, with that, Ed, I know you have a great list of questions for Dr. Murray, and so let's turn it right over to you both.

Ed Haines: Dr. Murray, first, you mentioned the American Society of Retina Specialists. I wonder if you could tell us a little bit more about that organization and why folks that listen to our podcast would want to know about it?

Dr. Tim Murray: So, the American Society of Retina Specialists is the single largest society of fellowship trained retina specialists in the United States, and really, in the world at the level of training that we have. And so, when you're looking in medicine, it's really sometimes difficult to find who's the expert and how do I know that I'm seeing someone that's been incredibly well-trained? And that's why I think the American Society of Retina Specialists is so important. It allows you to know that any person that is a member has excellent training credentials from a fellowship that has lasted two years and has met minimal requirements in surgical and medical training. I think that's critical for every patient that needs to be cared for.

Ed Haines: Well, that makes perfect sense. Because often, when people do understand that they have a problem with their retina, the tendency is to just find someone as quick as you can to help. But I agree with you, it really pays off to do your research and to look at an organization like yours to really find the help that's most appropriate. Let's just talk about the retina briefly, just so folks have at least a lay person's understanding of what it is you do. So, I wonder if you could describe just what the retina is and what is its role in healthy vision.

Dr. Tim Murray: So, I think the retina is the key to the vision that we enjoy. And for us that are a little bit older, the retina is much like the film in the camera. So, you know that light comes into the eye. It gets focused through the clear cornea and the lens, which allows us to focus the image, but what actually takes that image and transfers it in an electrical way to our brain so that we can see is the retina. So, if the retina doesn't function, you cannot see.

Ed Haines: Are there common conditions that generally retina specialists treat? Are there certain things that are seen more often than others?

Dr. Tim Murray: From a retina specialty perspective, the three most common things that we see turn out to be the most common blinding treatable diseases in the United States, age-related macular degeneration, which can cause central vision loss and central blindness, diabetic retinopathy, which is a sequelae of diabetes that occurs over time for patients that have had longstanding diabetes, and then vascular diseases such as a stroke in the eye. Those are the three most common conditions that are retina specialty focused and can blind you, but now are amazingly treatable.

Ed Haines: What's a journey that a patient travels when they get to see you? What's the sequence of events that brings them to your office typically?

Dr. Tim Murray: Much of the eye disease that we see in my office, including the majority of the eye cancers that I manage, have no symptoms at all. So, it's kind of scary. But for patients that come to us with symptoms, the most common symptoms that they have are sudden flashing lights, which we call photopsias, sudden loss of the vision, which we call a visual field loss. It can be a portion of the vision that's lost, like a curtain being pulled across, or it can be all of the vision. They can have this distortion of vision that we call metamorphopsia, which is a blurring of the central vision, or they can have floaters in their eye that appear suddenly that can be related to bleeding inside of the eye and related to potentially the development of retinal detachment.

Ed Haines: A lot of folks who have not been to a retinal specialist before I think assume that the experience is going to be kind of like going to their optometrist. They're going to knock on the office store and they're going to walk in and see their doctor. And I know from personal experience, that's not necessarily the case. So, I wonder if you could describe kind of what a new patient experience would be when they first visit a retinal specialist.

Dr. Tim Murray: So, for most retina specialists, we're referral-based, which means that you've seen an optometrist or another ophthalmologist that has seen you and recognized that you have a retina specialty problem and has referred you. And most of those referrals are actually quite urgent. So, they may see a tear in the retina or a detachment, or tumor, or evidence of a stroke, or bleeding from diabetes. So, most of our patients, when they're made aware that they need a retina specialist need one quickly. The other way that we get to see patients, Ed, is that a lot of times we have conditions that run in families. And so, we know that a family member may have a parent or a child or sibling that could have disease, and we'll actually, as the retina specialist, ask them to bring their family members in to be seen.

Ed Haines: And there is a component of genetic counseling as well that those folks would be offered?

Dr. Tim Murray: So, what's amazing is that we've seen such huge advances in genetics. And so, genetics are becoming more and more important in the decision-making for us in ophthalmology in general, but in retina in particular. So yes, we definitely do counseling. A lot of the genetics for this are incredibly complicated for these diseases. So, we often speak about familial risk, where we know that there's a genetic component, but the risk may be greater within the family. You probably know that the first genetic therapy ever to be approved was actually used in the eye recently, and it is a therapy that's targeted at curing childhood blindness from retinitis pigmentosa, kind of an amazing story.

Ed Haines: So that actually leads me to my next question. You've just answered it really, but a lot of folks, when they hear they have a retinal condition, they're pretty scared that this is going to result in permanent loss. So, can conditions ever be slowed down or even reversed?

Dr. Tim Murray: So that's the most important message to get across, Ed, I think is that these conditions that routinely were blinding in our grandparents' decade are now very treatable and the key to that is early diagnosis and seeing a specialist that's equipped to take the best care of the patient.

Ed Haines: And with treatment, let's talk about, for instance, age-related macular degeneration. I know 10 years ago, we didn't have the injections and wet type macular degeneration was really a disturbing problem. Now, people get injections. Do you have to get those for the rest of your life?

Dr. Tim Murray: So, first of all, the most important thing is to recognize that most types of macular degeneration, which is the dry type of macular degeneration, never need to be injected. So, it's very important to get the correct diagnosis, as you might imagine. And the technology to do that has become incredibly precise. We have technology now that's called OCT, or optical coherence tomography. It takes a laser scan of the retina, Ed, that is so precise, it's better than what I used to see in the microscope when I was in medical school.

So, it is a wow moment. And those testing evaluations allow us to be incredibly precise about how we treat the patient. And at this point, we really personalize our therapy. So, it is not one size fits all. Every patient gets personally identified and targeted treatment based on how they're responding. Some patients are blessed and may need one injection only and never need to be injected again, and some patients need to be injected for their lifetime. But having said that it's worth it to do it well. Because before these injections, and I'm a little bit more mature, every person that we took care of with wet macular degeneration went blind. I almost never see that. And when I do see that Ed, it's because somebody came late, or for some reason, they weren't able to continue to be treated. So that's an amazing change, even in the last 10 years.

Ed Haines: I do want to talk to you about dry macular degeneration briefly, and it's a question that I get asked in the field all the time from older adults. Essentially, I've had lots of clients that have said to me, "Well, my retinologist told me there's nothing that can be done. So why should I go back?" And so, what would you tell a patient that has that outlook?

Dr. Tim Murray: So, first of all, the reason why you want to be followed with dry macular degeneration is because it can convert from dry to wet, and wet is incredibly treatable and wet is typically the type of macular degeneration that leads to blindness. Dry macular degeneration usually doesn't have a significant impact in the visual function of the patient unless they develop what's called geographic atrophy. And that's literally where the retinal tissues in the center just become dysfunctional and they essentially wither away.

Fortunately, that's a very rare component of macular degeneration. And it's an exciting time for even that, Ed, because there are now some clinical studies starting to look at how we can treat the atrophic type of macular degeneration that affects vision. So, I think the last thing you want to do as a patient, when you have a condition that we know has long-term issues, is not to continue to be seen.

Ed Haines: I will tell you, I've had tons of people tell me that. And here's another misapprehension that I've heard over and over and over again. I can't tell you how many folks I've worked with that have told me, "Well, I didn't have macular degeneration until they removed my cataracts." And people are convinced that the cataract removal caused their macular degeneration. And I wonder what you'd say to a patient with that outlook.

Dr. Tim Murray: So, two things. One of the things that we try to teach our colleagues that are going to do cataract surgery is that it really is critical in this day and age to look at the macula with imaging before cataract surgery. Because if a patient has preexisting macular degeneration and that is the reason that the vision is being impacted, taking the cataract out is only going to unmask the macular degeneration. So, I think it's fair to counsel patients ahead of time by looking at the macula to say, "Look, we're going to take your cataract out, but you have macular degeneration, and it may require additional treatment by a retina specialist."

Also, Ed, I'll tell you that if you have your cataract removed and for any reason there is not a really good outcome visually, I think every one of those patients should see a retina specialist. Because many of the conditions that limit vision after cataract surgery are eminently treatable by a retina specialist. So, I think that's a big take home message for your clients and our listeners.

Ed Haines: That is really valuable because I know often, folks have those cataracts removed, they think everything is going to be great, and then things aren't and they really kind of lose the impetus to keep going with their eye treatments. So, thank you for that. Just to add another quick question, a couple of them, do you encourage folks to bring a partner or a spouse or an advocate in with them when they see you? I mean, this is a post-pandemic question, I guess.

Dr. Tim Murray: Well, I think that's one of the most important things that you do. I mean, all of us have been to see our physician, and you're in the midst of an exam and you're having a discussion. And often, you can't think of a single question while you're in the office and you think of a hundred while you're on the way home. The other thing is, is that often we have really intense discussions, and having someone with a second ear listening for you can really, really help.

So, I have always been a strong believer that every patient should have someone with them. And even in the pandemic, for our complicated patients, we will examine the patient without their family member or their spouse or their significant other, but, Ed, we'll bring them in at the end so that they can hear the discussion about how we're doing and what we're going to do. I think that's such an important part, is to understand what your doctor wants to do and why they want to do it and what you can expect.

Ed Haines: And that leads me to my next question actually. I know that retinal specialists, they have to see a lot of folks during the day, and you're concerned with the physiology of the eye. A lot of times your patients probably or could be thinking more about their functional vision in terms of how it's going to affect their daily life. So how can retina specialists make sure that folks who've received a devastating diagnosis know that there are other options besides your intervention that they can pursue? Is that even possible given the current structure?

Dr. Tim Murray: So, I think it is possible. I think you've been involved in counseling and clients and technology. The amount of sort of advances in the technologies for patients to be able to see better and to function better is huge and it is going to change in a major way, in a major positive way, even over the next five years.

And the other thing I'll tell you, Ed, is that this pandemic is driving me crazy because we're seeing more dry eye and more lid disease. So, I'm supposed to be the retina specialist and I spend just about as much time talking to my patients about how to treat their eyelid disease and how to keep their eye lubricated and what the impact of wearing a mask is and what the impact of not being in a normal routine. So, you're right, I like to focus on “I can fix the physiology and anatomy,” but I'm also aware that from my patient's perspective, all they're really interested in is, "Tell me that I'm going to see and how can I see better," and a lot of that takes place with things other than what I'm doing with their injection therapy or their OCT imaging.

So, I think you've really nailed it, and that's where these complimentary approaches become really helpful for our patients. And I think we can't emphasize enough that eating well and staying healthy and exercising. We really push, for macular degeneration, sort of those leafy green vegetables. There's been a big argument about the use of special multivitamins called AREDS2 for patients at high risk.

So, there are many things that we can do, and then even patients that have potentially had some impact negatively on their vision, technology and low vision assessment, better lighting and magnification, it's amazing how much better you can function with a little bit of help.

Ed Haines: Well, I'll maybe try to wrap things up by just asking you again about the American Society of Retina Specialists. I know they have a number of resources for patients and caregivers, and I wonder if you'd want to share some of those,

Dr. Tim Murray: The website, which is asrs.org/patients, that website has patient information. It actually has something I think is really cool, Ed, which is called Find Your Retina Specialist. So, you can put in where you live and it can tell you your retina specialist within 5, 10 and 15 miles. So, it can give you options as to who to see. It has patient-focused information pamphlets, a couple of which I've even been able be involved with. They're incredibly helpful. And then what we're trying to do is to reach out more to the patients. We've typically been about educating our retina specialist community and our colleagues, thanks to people like you and Hadley. We're trying to become more involved in giving our patients more options to help themselves.

The other place that I think is really excellent is the National Eye Institute. And they have really good information. You can certainly look on the internet, but I think it's good to try to have some idea of who's putting the information out there, because there is a lot of misinformation as well as good information on the internet.

Ricky Enger: That's such a great point, having the knowledge that you really are reading some information from an expert, rather than just something that you sort of found on the internet that maybe sounds good on paper, but just isn't true. We're going to have those resources, of course, in our show notes for those who want to check that out, I appreciate that. Dr. Murray, any final thoughts that we maybe didn't cover, or just something that you want to leave our listeners with?

Dr. Tim Murray: I think the biggest thing to know is that if you're not happy with your vision, see a specialist to allow them to explain to you what can be done. Don't give up. There are so many things that can be done now for patients that could not be done even 10 years ago. And I think that's the most important thing. So be empowered to ask for what's best for you.

Ed Haines: Dr. Murray, that's fantastic advice. I know that from personal experience.

Dr. Tim Murray: Guys, it was really good to be with you. Ricky and Ed, thank you so much.

Ed Haines: Well, Dr. Murray, thank you for your time. I know you're very busy. We're grateful for your attention.

Dr. Tim Murray: My pleasure.

Ricky Enger: Thank you both so much for joining us. Got something to say? Share your thoughts about this episode of Hadley Presents, or make suggestions for future episodes. We'd love to hear from you. Send us an email at podcast@hadley.edu. That's P-O-D-C-A-S-T@hadley.edu, or leave us a message at 847-784-2870. Thanks for listening.