Vision of the future

On the wall in Ahmed El-Amir’s consulting room in the Harley Street Eye Clinic is a framed antique poster depicting the world in two halves. ‘L’Ancien Monde et Le Nouveau’, reads the script. There is much about the surroundings that reflects the former — the glittering chandelier; the stacks of glossy magazines; the plush sofas with their tasselled cushions; the ornate gold maritime clock by the door. But the trappings of antiquity are illusory. For Mr El-Amir is the embodiment of ‘le nouveau’ — and it’s in this very room that he’s helped to pioneer a treatment which is turning science fiction into reality.

Over the past four years, this bright young surgeon — Oxford-educated and trained at the Moorfields Eye Hospital — has led the way in Britain when it comes to a groundbreaking new technique in the field of age-related macular degeneration (AMD). This debilitating condition, the biggest cause of sight loss in developed countries, affects older patients, causing blind spots in their central vision. It has no cure and, until recently, no restorative treatment was available either.

Building on ten years of international research, Mr El-Amir has developed a course of surgery that enables such patients to see again. He is also the only person in the world carrying out the procedure on people who’ve had previous eye surgery. ‘We have come so far,’ he explains. ‘As recently as eight or nine years ago, you would look at patients and say, “I’m sorry, there is nothing I can do.’’ ’

Mr El-Amir’s work involves implanting the world’s smallest telescope — 3.6mm in diameter by 4.4mm in length, roughly the size of a pea — into one eye. The telescope magnifies images by a factor of 2.7 and projects them beyond the damaged part of the eye (the macula) onto a wider area of healthy cells in the retina. This improves both near and distance vision, while the other eye provides peripheral vision.

Discussions began in 2010, at a round table of global ophthalmic experts in Liverpool, when the inventors of the telescope (known as ‘CentraSight’, and developed by an American company called VisionCare Ophthalmic Technologies) began investigating ways of turning scientific theory into surgical practice. ‘It took about a minute for me to stick my neck out and say I wanted to be the one to try it here,’ says Mr El-Amir. Just over a year later, after a series of clinical trials, he became the first person in Britain to carry out the surgery.

Since then, he has implanted telescopes into the eyes of 35 patients — and says his drive comes from seeing the drastic improvements this treatment makes to their quality of life. ‘My first case was a woman in her nineties — very fit, an avid sports viewer — who was in tears day and night because she couldn’t see her great-grandchild’s face. She was utterly distraught. I went through the pros and cons and told her it was possible it wouldn’t work. But it did. She was able to see her family again, and one of her most vivid moments was watching snooker on television and being able to see the ball hit the pocket.’

Mr El-Amir’s other patients have spanned a diverse range of backgrounds, nationalities and experiences. He has treated sportsmen and women (including a world-class archer); newsreaders; doctors; farmers; and sufferers from France, Italy and as far afield as Egypt and Canada. All had been crippled by the onset of AMD, which can occur slowly (‘dry’ AMD) or come on rapidly, even overnight (‘wet’ AMD). Dame Judi Dench — who revealed a few years ago that, because of her own AMD, she was struggling to read scripts or recognise faces — has been one of the most forthright campaigners for awareness of the illness. ‘Though I haven’t treated her, her description of the condition has made it really hit home,’ he says.

Unfortunately, not all AMD sufferers are suitable candidates for the procedure. There is a minimum age limit of 55, patients must have AMD in both eyes, and they should have been advised that other treatments will no longer help. Initially, another condition was that they must also not have had cataract surgery, but Mr El-Amir’s revolutionary approach meant that, by 2012, he was also carrying out surgery on patients who had had prior operations. He nicknames his version of the original treatment ‘MaculaScope’, and the second generation procedure ‘MaculaScope Plus’.

Macular-implant
The tiny telescope implant, balanced on a finger

One of his patients is Leslie Richardson, 87, a retired Post Office worker from Middlesex, who had surgery last July. ‘My sight was gradually getting weaker, and I had to give up driving,’ he explains. ‘That was a big blow — I couldn’t do my own shopping any more and started losing my independence. Since the operation, my sight has improved and it’s getting better by the day. I’m really happy, as are my family.’

AMD is a huge problem in Britain: more than 600,000 people are registered with the disease and around a further 1.5 million are thought to be living with its early-onset stages. In an ageing population, with life expectancy steadily increasing, its spread is set to continue — and experts emphasise its devastating nature. ‘It takes a terrible toll on those it affects,’ warns Caroline Abrahams of Age UK; while Derek Rix of Action for Blind People describes it as ‘difficult and overwhelming’. Its effects range from physical disability to depression, from social isolation to thoughts of suicide.

There is no doubt of the urgency of finding a solution — but what makes Mr El-Amir’s procedure particularly special?

The answer, he believes, lies in the telescope he uses. Handmade in Israel from quartz crystal, the miniature mechanism is composed of 40 separate parts, together mimicking the function of a full-sized telescope. ‘There are three or four technicians who work to the same microscopic standard as jewellers putting diamonds in rings,’ he explains. ‘It’s very technologically complex. And the next step, to disinfect it to make it aseptic, is even more exacting.’

Despite being so tiny, the telescope is still relatively large for an optical implant. In order to make space for it, Mr El-Amir uses a local anaesthetic to numb the eye and then creates a pocket by removing the eye’s natural lens. The implant is inserted behind the iris so it’s not noticeable; and the whole procedure takes between 60 and 90 minutes.

Prior to surgery, patients are required to pass a series of tests using an external telescope which replicates the effect of the implant, and afterwards they receive six weeks of rehabilitatory home visits from a specialist optometrist. They are given reading glasses to aid with near vision, and they learn how to combine the larger vision from the implanted eye with the peripheral vision from the unoperated one.

At present, surgery costs in the region of £11,000-£14,000, around £8,000 of which covers the telescope alone. The variation in price is due to the differing post-surgery needs of each patient. By raising awareness of the procedure, and increasing his pool of patients to 100, however, Mr El-Amir hopes to halve the cost by the end of 2016. Not only will this enable more people to afford the surgery, but it may increase its chances of being recommended by the National Institute for Health and Care Excellence (Nice) and eventually becoming available on the NHS. A report by Nice in 2009/2010 was favourable, and Mr El-Amir says his initial discussions with local healthcare providers have proved encouraging.

Others in the field are excited by such progress. ‘Any safe and effective intervention that enhances remaining vision and restores some sight will go a long way to improving our quality of life as we get older,’ says Mike Daw, chief executive of the National Eye Research Centre. ‘An innovation such as this obviously has potential.’

If you have advanced AMD, this is how the world might appear to you
If you have advanced AMD, this is how the world might appear to you

On the other hand, Cathy Yelf of the Macular Society, the UK’s leading charity in AMD support, raises concerns over the ‘tiny number of people’ the CentraSight implant can help, because of the difficulties that still remain. ‘This is certainly a way in which we are moving towards improving life for people whose vision has already gone,’ she acknowledges, ‘but many cannot cope with the enormous disparity in vision between one eye and the other. It requires scrupulous research if it is ever to become a mass solution.’

So what does the future hold? The threat of AMD is, after all, one that hangs over everyone — and it is becoming clear that the quest to restore sight will require some thinking outside existing medical parameters. The broader picture is optimistic: optical surgery has vastly improved over the past decade, from treating glaucoma with eye drops to repairing failing vision with stem cell therapy. In the field of AMD, too, there have been major developments: in the dry form, a vitamin supplement called the Areds 2 Formula can be prescribed to significantly reduce eyesight loss; in the wet version, a solution can be injected to reduce blood vessel growth and slow the rate of disease for up to ten years.

As for the telescope — the epitome of a ‘cyborg’ solution to a human problem — the outlook is hopeful. ‘There is no stopping now,’ predicts Mr El-Amir. ‘The materials we use will develop to reduce glare; to sharpen colour perception. It could also become injectable, and therefore less invasive.’ He grins. Le nouveau beckons.