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learn more about how various parts of the body respond to injury, and thereby

develop better ways of improving wound healing.

Since the genesis of vision research, scientists have wondered why the

eyeball sometimes grows excessively long during childhood, causing the common

problem of myopia, or nearsightedness.

I am happy to report this year that we

may at last have a compelling new clue about what causes this condition that

affects roughly one-third of the population. NEI - supported investigators have

recently produced exciting new evidence suggesting that local retinal

neurotransmitters.-molecules that allow communication between cells--may

actually play a role in the development of nearsightedness.

The researchers

have identified the neurotransmitter dopamine as a possible factor in the

control of the developing eye.

Indeed, dopamine - enhancing drugs were shown in

animal studies to partially protect the eye from myopic ēlongation. Although

this work is still in its early stages, these findings offer science an

intriguing new direction to follow in attempting to answer the age-old

question about the cause of myopia.

The National Eye Institute also continues to support clinical research on

new methods for the diagnosis and treatment of eye diseases.

I would like to

tell you about some of the more important of these clinical trial results that

were reported during the last year.

The first involves the ongoing Prism Adaptation Study (PAS).

About 4

percent of all Americans have some form of cross-eye, the inability to direct

both eyes to the same object.

For most individuals, surgery is the most

effective way to correct this disabling problem. Unfortunately, surgery is

not uniformly effective, since nearly half the patients who undergo surgery

need more than one operation to correctly realign their eyes.

But, in its preliminary findings, the PAS reported that patients who wear

eyeglasses with special prisms for one month prior to their operation are more

likely to undergo successful surgery.

If future study results bolster the

early finding, this marvelously simple strategy will yield considerable

savings in expense, trauma, and surgical risk for Americans with cross-eye.

The NEI - supported Glaucoma Laser Trial (GLT) also reported a very hopeful

early finding this past year. Traditionally, drugs have been used to treat

glaucoma, a sight-threatening increase in pressure Inside the eye.

However,

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the GLT found after two years of study that argon laser therapy appears to be

a safe and effective alternative to eye drops for newly diagnosed open-angle

glaucoma patients. Although these early findings are promising, GLT

clinicians will follow patients for an additional three years to better

determine the treatment's long-term safety and efficacy. This extended

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follow-up period is necessary because glaucoma is a chronic disease with a

variable rate of progression.

As NEI support of the GLT suggests, glaucoma continues to be an important

area of NEI research interest.

Two NEI - funded epidemiology studies, the

Barbados Eye Study and the Baltimore Eye Survey are providing reliable new

data on the prevalence of this potentially blinding disease.

For example,

Baltimore Eye Survey findings show that primary open-angle glaucoma is six

times more prevalent in Blacks over age 40 than in Whites.

Because glaucoma

is an age-related eye disease, these findings emphasize how important it is

that middle-aged Black people need to have a comprehensive, dilated eye

examination for glaucoma to reduce their risk of visual loss from this

disease.

One means that the NEI will utilize to encourage this practice is the

National Eye Health Education Program (NEHEP), a public education effort

mandated by the Congress.

After close consultation and interaction with

numerous voluntary and professional organizations, the NEHEP will this year

launch a multi-media campaign targeted to Blacks over age 40 and all people

over age 60 emphasizing the necessity of periodic glaucoma testing. Another

NEHEP program will be targeted to the nation's more than 14 million people

with diabetes who are at risk of developing diabetic eye disease, a leading

cause of adult blindness.

The NEI will also continue its efforts to help treat the devastating eye

complications of AIDS.

Specifically, cytomegalovirus (CMV) retinitis is the

most common cause of severe vision loss among AIDS patients, affecting an

estimated 25 percent of all victims of this disease.

Unfortunately, this

problem can be difficult to treat because both current drugs of choice,

ganciclovir and foscarnet, can have toxic side effects, and at best can only

control, not cure, the disease.

To learn more about the comparative safety and efficacy of these drugs in

AIDS patients, the NEI has begun the CMV Retinitis Trial.

This clinical trial

will evaluate the toxicity of ganciclovir and foscarnet, as well as monitor

these drugs' effects on patient health and survival.

The CMV Retinitis Trial

is the first study conducted under a collaborative clinical research project

called Studies of the Ocular Complications of AIDS (SOCA).

SOCA has been

designed so that as promising new therapies for AIDS-related eye diseases

become available, they can be rapidly tested in a scientifically rigorous

manner.

Before concluding, I would like to reiterate the great social benefit of

vision research.

Indeed, since most people rely on vision for virtually all

aspects of their daily lives, Institute-supported studies will continue to

have a great impact in helping all Americans, young and old, maintain a high

quality of life.

As always, I look forward to keeping this Committee informed

of the great progress that future vision research will certainly bring to the

American public.

Mr. Chairman, the FY 1992 budget request for the National Eye Institute

is $272, 260,000.

I will be glad to answer any questions that the Committee

might have.

BIOGRAPHICAL SKETCH OF DR. CARL KUPFER

Director, National Eye Institute
February 9, 1928. New York, New York.

Education: A.B., Yale Univ., 1945-48. M.D., The Johns Hopkins Medical
School, 1952 Certified. Amer. Bd. of Ophthalmology, 1958.

Professional History: Internship and Assistant Residency, Wilmer Eye Inst.,
Johns Hopkins Hospital, 1952-54. Lab. Assistant, Biostatistics, Johns Hopkins
School of Medicine, 1953-58. Research Fellow in Ophthalmology, Harvard
Medical School, 1958-60. Instructor in Ophthalmology, Harvard Medical School,
1960-62. Asst. Prof. of Ophthalmology, Harvard Medical School, 1962-66.
Prof. and Chairman in Ophthalmology, Univ. of Wash. School of Medicine;
Research Affiliate, Univ. of Wash. Primate Ctr., 1966-70.

Professional Organizations: Amer. Physiological Society; Assoc. for Research in Vision and Ophthalmology; American Academy of Ophthalmology; American Ophthalmological Society: Pan American Ophthalmological Society; Johns Hopkins Univ. Soc. of Scholars; Member, Inst. of Medicine, Nat'l Academy of Sciences.

Honors and Awards: The Secretary's Special Citation, Dept. of Health, Education and Welfare (DHEW), 1972; The Superior Service Award, DHEW, 1974; Presidential Rank Award of Meritorious Exec., 1983; Migel Medal, Amer. Foundation for the Blind, 1976; Public Service Award in Ophthalmology, Amer. Acad. of Ophthalmology and Otolaryngology, 1977; Special Award of Honor, The Assoc. for Research in Vision and Ophthalmology, 1983; David Rumbough Memorial Scientific Award, The Juvenile Diabetes Found., 1983; The Lighthouse Pisart Vision Award, 1984; Cavera Medal of Univ. of Rome, 1985; The Mildred Weisenfeld Award for Excellence in Ophthalmology. 1987. President's award for distinguished excellence in the Senior Executive Service, 1990.

Invited Lecturer: Dunphy Lecture, 1977; Lorand V. Johnson Lecture, 1980; C.
Dwight Townes Memorial Lecture, 1981; Glenn A. Fry Award Lecture, Amer. Acad.
of Optometry, 1981; Richard Stein Lecture, Maurice and Gabriella Goldschleger
Eye Inst., Tel-Aviv Univ., Sackler School of Med., Israel, 1982; Jules Stein
Lecture, L. A., Calif., 1983; Bowman Lecture, The Ophthalmological Soc. of the
U. K., London, England, 1984; Seymour Roberts Memorial Lecture, Stanford Univ.
Med. Ctr., Stanford, Calif., 1984; Doheny Lecturer, Univ. of So. Calif., 1984;
Everett Kinsey Lecturer, Contact Lens Assoc. of Ophthalmologists and
Internat'l Soc. for Refractive Keratoplasty, Las Vegas, Nevada, 1987.

Other Scientific Activities: Editorial Bd, Investigative Ophthalmology,
1969-77; Editorial Bd, American Journal of Ophthalmology, 1971-83; Mbr,
Scientific Advisory Committee, Fight for Sight, 1971-present; Mbr, Nat'l
Diabetes Advisory Board, 1976-present.

International Appointments: Mbr, Brd. of Trustees, Helen Keller Internat'l Inc., 1975-pres't; Coord. V.S. -Japan Collaborat. Agree'nt in Vision Research, 1976-pres't; Mbr, Internat'l Vitamin A Consultative Group, WHO, 1973-pres't; Mbr of U.S. Delegation to World Health Assembly, 1978; Mbr, WHO Advisory Group for Prevent. of Blindness Prog., 1978-84; Consultant, Pan Amer. Hlth Org., 1978-pres't; Coord. for USA, Priority Area "Eye Diseases," U.S. -V.S.S.R. Prog. for Health Cooperation, 1978-pres't; Mbr, WHO Expert Advis. Panel on Trachona and Prevent. of Blindness, 1979-pres't; dir., WHO Collabor. Ctr. för the Prevent. of Blindness, Nat'l Eye Inst., Bethesda, MD, 1979 -pres't; Pres., Internat'l Agency for the Prevent. of Blindness, Oct. 1982 -Nov. 1990.

DETERIORATING VISION

Senator HARKIN. I just learned something new that I will have to remember. The back part of the eye is part of the brain.

Dr. KUPFER. Yes, sir; it is.
Senator HARKIN. I'll have to think more about that.

Tell me this. Why is this? When I was 30 years old and a fighter pilot in the Navy, I had 20/15 vision. I had great eyesight. And about age 43, 44, somewhere in there, all of a sudden there were things I couldn't read too well any longer. So, I had to get a pair of glasses, and they gave me these reading glasses. Then it got worse and worse. I am now 51. It seems like I went along and it took one drop and it sort of leveled off. Then it took another drop. Now it has leveled off, and I have to wear these now. Why is that?

I can understand if you are born with an unhealthy eye or something, but when you have really healthy eyes and you have good eyesight, what happens? Why does it always happen around ageas I am told, around 45 to 50 years of age?

Dr. KUPFER. That is correct. Your information is quite correct.

The ability for us to look from a distance to near depends on changing the shape of the lens inside our eye. This ability to change the shape begins to decrease about the age of 40. So, that is why we need help from reading glasses or bifocal contact lenses, such as I and others wear to enable us to see what is close.

Now research is being done on this condition, as you might imagine. It is very distressing, especially for those of us who have never worn glasses. Perhaps in the next 5 or 10 years we will have ways to correct this problem.

Senator HARKIN. I can't wait. (Laughter.]
How much more money do you need in your budget? (Laughter.]

Dr. KUPFER. I think this will happen within our budget at the moment.

GLAUCOMA TREATMENT Senator HARKIN. I wanted to ask one other question about glaucoma. Two typical treatments for glaucoma are medications, which reduce the pressure, and surgery to accomplish the same purpose. What can you tell us about the relative effect of these two approaches and quality of life considerations? Which is the better approach? Or is there one that is better than the other, or does it depend upon the situation?

Dr. KUPFER. That is an excellent question. The situation with glaucoma is that it is completely asymptomatic. This is the openangle glaucoma which is the most common. Therefore, the individual can lose visual function without really being aware of any signs or symptoms until very late. When the diagnosis is made, we ask the patient to take drops. These drops themselves sometimes have adverse effects, plus the fact that it is very difficult to remember to take drops once, twice, or three times a day.

On the other hand, to lower pressure, another possibility would be to perform a surgical intervention which creates a new path for the fluid to leave the eye.

We do not know which is the better intervention. As a matter of fact, we are considering supporting a clinical trial which will randomly assign individuals who are newly diagnosed as having glaucoma to either medical treatment or surgical treatment with one of the major outcomes being which offers a better quality of life. So, in a number of years—hopefully not more than 3 or 4—we will begin to have information on this very question.

I might say that in the United Kingdom, surgery is now used as the primary intervention, whereas in the United States, we still prefer medical treatment as the primary intervention. This clinical trial will give us a very definitive answer.

QUESTIONS SUBMITTED BY THE SUBCOMMITTEE Senator HARKIN. Good. I look forward to that.

Dr. Kupfer, thank you. I have some additional questions which we will submit to you in writing.

[The following questions were not asked at the hearing, but were submitted to the Department for response subsequent to the hearing:)

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