- The podcast episode features Dr. Jeffrey Goldberg, an expert in eye health and vision.
- They discuss various topics related to eye health, including the benefits and drawbacks of corrective lenses, the effects of sunlight on vision, eye exercises, LASIK surgery, contact lens care, dry eye remedies, and nutritional approaches to maintaining and improving vision.
- The episode provides information relevant to individuals with vision issues, those considering changing their eye prescription, and those interested in enhancing their vision.
- They also discuss advanced technologies for preventing and offsetting vision loss due to diseases like glaucoma, retinitis pigmentosa, and macular degeneration.
- The podcast is part of an effort to provide free science-based information to the general public.

- Eye exams for babies are usually only done during regular well child checks
- Amblyopia screening exams are often done in elementary school
- Misalignment of the eyes and nearsightedness can trigger an eye exam in school-aged children
- Correcting eye misalignment early is important to prevent permanent vision loss
- The brain's plasticity allows for correction of misalignment even in older children and teens
- Full recovery of depth perception may not be possible even with correction
- Misalignment of the eyes for a few hours or days is unlikely to cause permanent vision problems, but prolonged intermittent misalignment can lead to issues
- Most children do not need to worry about occasional events like patching or closing one eye

- The majority of eye issues in children are not serious and do not require worry from parents
- Spending excessive time on near activities, such as using iPads and phones, can lead to myopia in children
- Recent studies suggest that outdoor lighting time may be more important than near work in preventing myopia
- Randomized controlled trials are needed to determine the optimal amount of outdoor time for children
- Outdoor time and full spectrum light may have additional benefits for eye health in older individuals, but the focus should be on exercise and overall health.

- The speaker discusses the exercise benefits of being outdoors and the importance of eye safety.
- Eye safety is crucial, especially for those working in certain industries or engaging in activities like gardening or woodworking.
- Eye trauma can lead to inflammation and serious injury.
- Regular eye washing is not necessary for most people, as tears and blinking keep the eyes clean.
- However, cleaning the eyelashes with a diluted baby shampoo or eye scrub pads can help with eye comfort.
- If something gets in the eye, using a sterile saline solution or artificial tears can help rinse it out.
- Occasional eye rubbing is generally harmless, but excessive rubbing can be dangerous in certain conditions.

- Optometrists and ophthalmologists have overlapping roles in eye care
- Optometrists have an optometry degree, while ophthalmologists have a medical degree and surgical training in ophthalmology
- Both can diagnose and prescribe eye drop treatments
- Only ophthalmologists can perform eye surgeries
- It is recommended to get regular eye exams, especially after age 40
- Eye exams can include checking eye pressure, looking at the surface of the eyes, and screening for diseases
- Presbyopia, the loss of ability to focus on near objects, is common after age 40 and may require reading glasses
- The use of glasses as a crutch can be problematic, but some people find them helpful for clearer vision

- The speaker shares a personal story about discovering the need for reading glasses.
- They discuss the addictive nature of good vision and the dependence on reading glasses.
- The speaker mentions that using reading glasses may accelerate the progression of dependence.
- They explain that as people age, their ability to shape the lens of the eye weakens, requiring stronger magnifiers.
- The speaker recommends getting a full screening exam at an eye office to monitor eye health.
- There is debate about whether using reading glasses weakens the eyes or if it is better to delay their use.
- The speaker suggests that exercising the eye muscles may slow the progression of dependence on reading glasses.
- However, they also argue that it is ideal to give the retina and brain the sharpest visual signals possible.
- The speaker advises wearing the glasses that provide the best vision and enjoying good vision all the time.
- They mention that driving at night can be a strain on the visual system and corrective lenses may be helpful.
- The speaker discusses the biology underlying difficulties with night vision and the potential need for corrective lenses.
- They conclude that many optical defects can be corrected with the right prescription lenses.

- The speaker discusses how optical defects in the eyes can often be corrected with prescription lenses.
- They explain that during brighter light conditions, one may not need to use corrective lenses and can still see clearly.
- However, in dim light or at night, the use of corrective lenses may be necessary to compensate for blurry vision.
- The speaker suggests that if someone experiences blurry vision while driving at night, it may indicate a need for glasses.
- They mention the possibility of being a latent hyperope, where the optical system of the eye is designed to focus beyond infinity, resulting in slightly out of focus vision at a distance.
- The speaker also shares a personal experience of using corrective lenses and how it affected their eye position and vision.
- They discuss the importance of critical period plasticity and the question of when to rely on corrective lenses versus natural vision.
- The speaker mentions the difference between the muscles inside the eye and the muscles on the outside that control eye movement and alignment.
- They explain that undercorrecting and exercising the eye muscles can be a common treatment for aligning the eyes properly.
- The speaker emphasizes the importance of consulting an eye care provider, such as an optometrist, for proper assessment and treatment.

- Dr. Jeffrey Goldberg discusses various topics related to eye health and vision in a podcast episode.
- They cover the benefits and drawbacks of corrective lenses, the effects of sunlight on vision, eye exercises, LASIK surgery, contact lens care, dry eye remedies, and nutritional approaches to maintaining and improving vision.
- The episode provides information relevant to individuals with vision issues, those considering changing their eye prescription, and those interested in enhancing their vision.
- They also discuss advanced technologies for preventing and offsetting vision loss due to diseases like glaucoma, retinitis pigmentosa, and macular degeneration.
- The podcast aims to provide free science-based information to the general public.
- Eye exams for babies are usually done during regular well child checks, while amblyopia screening exams are often done in elementary school.
- Misalignment of the eyes and nearsightedness can trigger an eye exam in school-aged children, and correcting eye misalignment early is important to prevent permanent vision loss.
- Spending excessive time on near activities, such as using iPads and phones, can lead to myopia in children, but recent studies suggest that outdoor lighting time may be more important in preventing myopia.
- Eye safety is crucial, especially for those working in certain industries or engaging in activities like gardening or woodworking.
- Regular eye exams, especially after age 40, are recommended to check eye pressure, screen for diseases, and address presbyopia.
- The use of reading glasses may accelerate the progression of dependence, but exercising the eye muscles may slow it down.
- Corrective lenses may be necessary for clear vision in dim light or at night, and blurry vision while driving at night may indicate a need for glasses.
- Undercorrecting and exercising the eye muscles can be a common treatment for aligning the eyes properly, but it is important to consult an eye care provider for proper assessment and treatment.

- Near-far exercises like pencil pushups can be beneficial for certain eye conditions, such as convergence insufficiency.
- These exercises are not harmful and may help slow down the progression of Presbyopia.
- Pencil pushups and smooth pursuit tracking exercises are used in the recovery from concussion to improve smooth eye movements.
- It is safe for anyone to do these exercises and they may enhance visual activity.
- There is ongoing research on improving vision performance beyond normal levels, such as training for athletes and improving night driving abilities.
- The new Vision Performance Center at Stanford is studying the difference between normal and supernormal vision and exploring ways to train and measure that difference.
- The goal is to redefine what is possible for vision, similar to physical training protocols for overall performance.

- 20/20 vision means being able to read the smallest letters at 20 feet that the average healthy person can read at 20 feet.
- Vision worse than 20/20 means being able to read at 20 feet what a normal person could read at a greater distance.
- Legal blindness in the US is typically 20/200 or worse.
- Some athletes, fighter pilots, and people who have had LASIK surgery can have better than 20/20 vision, such as 20/15 or 20/10.
- Visual acuity refers to the vision in the center of your vision, while the edges have lower resolution.
- Newborn babies have blurry vision and can't see fine details.
- Some species, like hawks and owls, naturally have better vision than humans.
- Contact lenses can affect tear dynamics and oxygen diffusion, but most people can tolerate them well.
- Contact lenses can correct different elements of the shape of the eye and higher-order aberrations that glasses can't correct.
- Contact lenses can trap bacteria or fungus, leading to corneal infections, so proper cleaning and use is important.
- Daily contact lenses are recommended for better hygiene.

- The speaker recommends using daily disposable contact lenses for convenience and eye health.
- Sleeping in contact lenses increases the risk of bacterial infections and reduces oxygen flow to the eyes.
- UV light is harmful to the eyes and can cause damage and cataracts.
- Blocking UV light is standard in eyeglasses, but the effectiveness of blue blockers is uncertain.
- Wearing sunglasses and a wide-brimmed hat can protect the eyes from UV light and reduce the risk of skin cancer.
- There may be variations in sensitivity to light based on eye color, but it has not been formally studied.

- The duration of eye dilation after using eye drops varies between individuals with different eye colors
- There are biological differences in the irises and their muscles between light-eyed and dark-eyed people
- LASIK eye surgery reshapes the cornea to correct vision problems
- LASIK can be a good option for people who are athletic, have severe prescriptions, or dislike wearing glasses or contacts
- LASIK is generally not recommended for children or young teenagers due to the changing shape of the eye
- Dry eye is a common eye condition, and the quantity and quality of tears decrease as we age
- Artificial tears can replace the saltwater part of tears, but the oil part is more difficult to replace

- Preservative-free artificial tears can be used frequently without harm
- Activities like reading, using the computer, and watching TV can reduce tear production
- The oily part of tears helps prevent evaporation and is difficult to replace effectively
- Dry eye is a major issue and can be managed with over-the-counter artificial tears and eyelid cleaning
- Inflammation can worsen dry eye symptoms and anti-inflammatory drops may be prescribed
- Research is being done on using blood serum, rich in growth factors, as a treatment for severe dry eye
- Preservative-free artificial tears are recommended for frequent use to avoid irritation and inflammation
- PRP (platelet-rich plasma) is not currently used in ophthalmology clinics for dry eye treatment

- PRP plasma is being studied for its potential use in treating ocular conditions, but it is not yet a standard of care in ophthalmology.
- The major causes of vision loss include refractive error, cataract, and glaucoma.
- Cataract surgery is a successful treatment, but access to care is a challenge in developing countries.
- Glaucoma is the leading cause of irreversible vision loss and is characterized by the degeneration of the optic nerve.
- Glaucoma can be managed by reducing eye pressure through medications, lasers, and surgeries.
- Access to glaucoma treatments and early detection are challenges, and peripheral vision loss can go unnoticed until late stages of the disease.
- There is currently no targeted treatment for optic nerve degeneration in glaucoma.

- Near-far exercises like pencil pushups can benefit certain eye conditions and may slow down the progression of Presbyopia.
- Pencil pushups and smooth pursuit tracking exercises are used in concussion recovery to improve smooth eye movements.
- Ongoing research is being conducted to improve vision performance beyond normal levels, such as training for athletes and enhancing night driving abilities.
- The Vision Performance Center at Stanford is studying the difference between normal and supernormal vision and exploring ways to train and measure that difference.
- Different levels of visual acuity exist, with 20/20 vision being considered normal.
- Contact lenses can affect tear dynamics and oxygen diffusion but are generally well-tolerated.
- Proper cleaning and use of contact lenses are important to avoid corneal infections.
- Daily disposable contact lenses are recommended for better hygiene.
- UV light can cause eye damage and wearing sunglasses and a wide-brimmed hat can help protect the eyes.
- There may be variations in light sensitivity based on eye color, but this has not been formally studied.
- LASIK eye surgery can correct vision problems and is a good option for certain individuals.
- Dry eye is a common condition that can be managed with artificial tears and eyelid cleaning.
- Inflammation can worsen dry eye symptoms and anti-inflammatory drops may be prescribed.
- Cataract surgery is a successful treatment, but access to care is a challenge in developing countries.
- Glaucoma is the leading cause of irreversible vision loss and can be managed through various treatments.
- Early detection and access to glaucoma treatments are challenges, and there is currently no targeted treatment for optic nerve degeneration in glaucoma.

- Glaucoma, optic neuropathies, age-related macular degeneration, and diabetic retinopathy are major causes of irreversible vision loss.
- Age-related macular degeneration is more common in developed countries with larger Caucasian populations and is a leading cause of vision loss in the elderly.
- There are two forms of macular degeneration, with the dry form causing slow degeneration of the rods, cones, and support cells in the retina.
- Some patients with the dry form may convert to the wet form, where new blood vessels grow and cause acute vision loss.
- Treatments for wet macular degeneration include injections that fight against the molecules causing new blood vessels to grow.
- Exciting news about a treatment for the dry form of macular degeneration has recently emerged, but it only slows the progression of the disease.
- Retinitis pigmentosa is an inherited form of macular degeneration that affects the rods, cones, and support cells and can cause severe vision loss at an early age.
- Diabetic retinopathy is a major complication of diabetes, with damage to the retina caused by new blood vessels or leaky blood vessels.
- Early screening and regular eye exams are important for individuals with diabetes to detect and manage diabetic retinopathy.
- The retinopathy is similar in type 1 and type 2 diabetes, but the time to presentation may differ.
- Prevention and treatment of diabetic retinopathy involve insulin management, controlling obesity, and maintaining blood sugar levels.

- Type 2 diabetics need to control their obesity and blood sugar levels
- Glucagon-like peptide mimics like Ozempic can help reduce diabetic retinopathy
- Regular eye exams are important for detecting and managing diabetic retinopathy
- Controlling blood sugar and blood pressure is crucial for preventing diabetic retinopathy
- Lifestyle changes like improving diet and exercise can help control blood sugar and blood pressure
- Treatments are available for diabetic retinopathy if blood sugar and blood pressure control is not enough
- Glaucoma screening exams are important as there are usually no symptoms in the early stages
- Lowering eye pressure can slow the progression of glaucoma, even if pressure is initially normal
- Eye drops and laser treatments are common first-line treatments for glaucoma
- Surgical approaches may be necessary if eye drops and lasers are not enough
- Glaucoma can lead to significant vision loss and blindness, making treatment adherence crucial
- Aging, smoking, and alcohol are risk factors for glaucoma and macular degeneration

- Smoking and vaping are harmful for eye health, especially for macular degeneration and glaucoma.
- Genes are associated with macular degeneration and pediatric forms of glaucoma.
- Cannabis can lower eye pressure but is not a practical long-term solution for most patients.
- Sleeping with the head elevated may help lower eye pressure at night for those with glaucoma.
- The side on which a person sleeps does not significantly impact glaucoma progression.
- Red light exposure may offset vision loss in age-related macular degeneration, but more research is needed to determine the effectiveness of this protocol.

- Red or near infrared light therapy shows potential as a neuroprotective treatment for eye conditions.
- Studies have shown positive results in animal models and some human data for macular degeneration and optic neuropathies.
- There are ongoing studies to determine the optimal dose, brightness, wavelength, and timing of light therapy.
- Red light and violet light in small daily doses have also been found to prevent nearsightedness in children.
- Light therapy may be filling in the gaps of sunlight exposure that is lacking in modern indoor and screen-focused lifestyles.
- Floaters in the eye are caused by the shrinking and contraction of gel in the middle of the eye and usually go away on their own.
- Twitching of the eyelid is often caused by a single nerve cell misfiring, and typically resolves on its own within a few months.
- Carrots are associated with good vision due to their vitamin A content, which is important for the eye's photosynthesis pathway.
- While vitamin A deficiency is not common in developed countries, there is a growing market for supplements promoting eye health and longevity.

- Ophthalmology has a longer history of exploring supplementation through rigorous trials compared to other areas of neuroscience
- ARIDS studies showed that supplements containing vitamin C, vitamin E, zinc, copper, and beta carotene can slow the progression of macular degeneration
- ARIDS-2 study found that a formula without beta carotene but with lutein and zeaxanthine was even better at slowing macular degeneration
- High-dose vitamin B3 shows promise in protecting against glaucoma and optic nerve degenerative diseases, with ongoing clinical trials
- Other supplements like ginkgo biloba lack scientific evidence and may not be effective
- Supplements should be used as a supplement to a healthy lifestyle and prescribed medication

- The neural retina is part of the brain and can be used to detect neurodegeneration.
- Imaging the retina is a non-invasive way to detect degeneration in the brain.
- Retinal degeneration is correlated with degeneration in other brain structures in diseases like Alzheimer's, Parkinson's, and MS.
- The specificity of differentiating between diseases based on retinal degeneration is still a challenge.
- New imaging techniques are being developed to detect specific structures in the retina associated with diseases like multiple sclerosis.
- The goal is to use retinal imaging as a diagnostic tool and to develop precision medicine approaches for eye health and overall health.

- Glaucoma, macular degeneration, diabetic retinopathy, and optic neuropathies are major causes of irreversible vision loss.
- Macular degeneration is more common in developed countries with larger Caucasian populations and is a leading cause of vision loss in the elderly.
- There are two forms of macular degeneration: dry and wet. The dry form causes slow degeneration, while the wet form causes acute vision loss.
- Treatments for wet macular degeneration include injections that fight against the growth of new blood vessels.
- A treatment for the dry form of macular degeneration has been discovered, but it only slows the progression of the disease.
- Diabetic retinopathy is a major complication of diabetes, and early screening and regular eye exams are important for detection and management.
- Controlling blood sugar and blood pressure is crucial for preventing diabetic retinopathy.
- Glaucoma screening exams are important as there are usually no symptoms in the early stages.
- Lowering eye pressure can slow the progression of glaucoma, and eye drops and laser treatments are common treatments.
- Lifestyle changes, such as improving diet and exercise, can help control blood sugar, blood pressure, and prevent eye conditions.
- Red light exposure and light therapy show potential as neuroprotective treatments for eye conditions, but more research is needed.
- Supplements containing vitamins and minerals have shown promise in slowing the progression of macular degeneration.
- Retinal imaging is a non-invasive way to detect degeneration in the brain and may be used as a diagnostic tool for various diseases.

In this episode, my guest is Jeffery Goldberg, MD, PhD, professor and chair of the department of ophthalmology at the Byers Eye Institute at Stanford University. His clinical and research efforts focus on retinal and optic nerve diseases such as glaucoma and discovering stem cell and nanotechnology treatments to cure blindness. We discuss how to maintain and improve eye health throughout life, the advantages and disadvantages of corrective lenses, including if you should wear “readers,” the use and risks of contact lenses, considerations for LASIK eye surgery, floaters, dry eye, the importance of sunlight and UV protection and specific exercises to improve eye and vision health. Dr Goldberg also explains age-related conditions: cataracts, glaucoma, macular degeneration and diabetic retinopathy; and the behavioral and supplementation-based, prescription and surgical tools used to promote eye health. This episode provides essential tools for listeners of any age and background to maintain eye health and offset vision loss.
For the full show notes, visit hubermanlab.com.
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Timestamps
(00:00:00) Dr. Jeffery Goldberg
(00:03:08) Sponsors: Maui Nui, LMNT, Eight Sleep
(00:06:29) Childhood & Eye Exams
(00:11:36) Eye Misalignment & Recovery
(00:20:38) Myopia (Near-Sightedness), Children & Sunlight
(00:30:04) Sponsor: AG1 (Athletic Greens)
(00:31:18) Eye Safety & Protection; Eye Hygiene
(00:40:07) Adults & Eye Exams; Optometrist vs Ophthalmologist
(00:46:35) Presbyopia (Age-Related Vision Decline), Reading Glasses
(00:54:54) Reading Glasses: Use & Recommendations
(00:58:34) Night Vision & Glasses
(01:02:55) Sponsor: InsideTracker
(01:03:54) Corrective Eye Glasses, Exercises
(01:09:52) Near-Far Exercise & Presbyopia; Smooth Pursuit Exercise & Concussion
(01:13:25) Supranormal Vision & Performance Training
(01:19:11) 20/20 Vision; Visual Acuity
(01:24:51) Contact Lenses: Use, Risks & Aging
(01:31:34) UV Protection & Cataracts, “Blue Blockers”
(01:38:20) Light Sensitivity & Eye Color
(01:40:29) LASIK Eye Surgery
(01:46:26) Dry Eye, Tears & Age
(01:53:24) Dry Eye, Serum Tears & Preservative-Free Artificial Tears; PRP
(02:00:46) Vision Loss: Cataracts, Glaucoma
(02:09:23) Age-Related Macular Degeneration, Dry & Wet Forms
(02:14:02) Diabetic Retinopathy, Type I vs Type II Diabetes
(02:18:54) Diabetic Retinopathy Treatment, Blood Pressure
(02:22:17) Glaucoma Screening & Treatment
(02:28:07) Smoking, Vaping & Vision Diseases; Cannabis & Eye Pressure
(02:35:13) Eye Pressure & Sleep Position
(02:37:48) Macular Degeneration, Optic Neuropathies & Red-Light Therapy
(02:42:23) “Floaters”
(02:45:29) Eye Twitching
(02:48:10) AREDS2 Supplementation & Age-Related Macular Degeneration
(02:53:39) Glaucoma & Vitamin B3 Supplementation
(02:58:42) Retinal Imaging & Neurodegeneration Screening, Multiple Sclerosis
(03:06:30) Zero-Cost Support, YouTube Feedback, Spotify & Apple Reviews, Sponsors, Momentous, Social Media, Neural Network Newsletter
Title Card Photo Credit: Mike Blabac
Disclaimer

Welcome to the Huberman Lab Podcast, where we discuss science and science-based tools for everyday life.

I'm Andrew Huberman, and I'm a professor of neurobiology and ophthalmology at Stanford School of Medicine.

Jeffrey Goldberg is the chair of the Department of Ophthalmology at Stanford University School of Medicine.

He is a clinician, an MD or medical doctor who sees patients every week, as well as a PhD, meaning a laboratory scientist who directs his own laboratory focused on understanding the mechanisms and cures for diseases of the eye and vision, such as glaucoma, retinitis pigmentosa, and macular degeneration.

Goldberg is 1 of the world leaders in developing methods to cure blindness.

He is also intensely knowledgeable about all things related to vision.

So during today's discussion, we indeed cover most all of visual and eye health.

You will learn, for instance, about the benefits as well as drawbacks of wearing corrective lenses, such as contact lenses or eyeglasses for reading.

You will learn about the benefits and detriments of sunlight, meaning how it can help your vision.

In fact, how it can help reverse or prevent myopia, nearsightedness, as well as the things to be cautious about with respect to sunlight in terms of development of cataracts, which are occlusions that prevent vision.

We also discuss many tools for maintaining and improving vision across the lifespan, ranging from behavioral tools, so specific vision tasks and exercises for the eye that you can do that are known to improve or maintain your vision, as well as specific surgical procedures, such as LASIK surgery.

We get into all the details of, for instance, how often to do these various eye exercises, how long the benefits are maintained, as well as age-related considerations for things like LASIK eye surgery.

We even get into how to best clean your contact lenses, whether or not to use disposable contact lenses or other forms of contact lenses.

We also discuss things like dry eye and the best remedies for dry eye.

And we talk about the scientific and clinical data around nutritional approaches and supplementation-based approaches for maintaining and improving vision.

So whether or not you suffer from floaters or dry eye, or you're considering changing your eye prescription, or you have concerns about whether or not relying on corrective lenses is impairing your vision and you want to enhance your vision, or if you're somebody who has perfect vision, today's episode is going to include science and protocols that will be highly relevant to you.

I should also add that if you are somebody who suffers from or who has family members who suffer from diseases of the eye that can impact vision, such as glaucoma, retinitis pigmentosa, and macular degeneration, we also delve deep into the discussion about the most advanced technologies for preventing and offsetting vision loss due to those diseases as well.

Goldberg's incredible knowledge, his clarity of communication, and his generosity with that knowledge.

By the end of today's episode, you will be armed with all of the modern information you need in order to best maintain and improve your eye and vision health.

Before we begin, I'd like to emphasize that this podcast is separate from my teaching and research roles at Stanford.

It is however, part of my desire and effort to bring 0 cost to consumer information about science and science related tools to the general public.

In keeping with that theme, I'd like to thank the sponsors of today's podcast.

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Element is an electrolyte drink that has everything you need, that is the electrolytes, sodium, magnesium, and potassium, but nothing you don't, which means no sugar.

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Today's episode is also brought to us by 8sleep.

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When we're sleeping well and we're sleeping long enough, everything in our daily life goes that much better.

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We will spare people the discussion about all of that, but I'm really excited for today's discussion because I get a tremendous number of questions about vision and eye health.

And of course, as a neuroscientist who has worked on the visual system, I sometimes have answers or partial answers, but more often than not, I don't have the answers.

And yet I'm confident that you do, or that if you don't, you can direct us to the proper place to get those answers.

So to kick things off, I wanna ask you what was 1 of the most commonly asked questions when I solicited for questions in anticipation of this episode, which is how early should 1 do an eye exam on their child?

And how regularly should we all be doing eye exams?

Also is the fact that I think I can see normally, confirmation that I can see as well as I think I can.

So that's really 3 questions, but baby comes out, do they check their eyes right away?

And if so, how and how often should they check and what kind of information is there?

It's obviously something that touches us all.

So the answer that really differs a little bit at the different stages of life.

First of all, every baby gets an eye exam or should be getting an eye exam.

And 1 of the main things that you really just are screening for right when that baby is born, right in the nursery, right in those first few days, is to just look for a red reflex.

You know, when you take a camera picture, a flash picture, and sometimes you get red eye, that's actually the light from the flash, as you know, reflecting against the retina and coming back out of your eye, it looks red.

And a red reflex is actually very normal.

And if you have 1 of a number of diseases in the eye that can present even in babies, even in newborn babies, including most concerning, but thankfully least common, retinoblastoma, which is the most common pediatric eye cancer, which again, thankfully, is quite rare, those babies won't have a red reflex in that eye.

It'll be kind of a whitish or gray reflex.

And so even just that first little, you know, doctor's taking the little pen light and even just flashing it in the baby's eyes.

And hopefully, every baby being born today is getting that first eye exam, is really just looking for that red reflex.

It's not typical, as long as that's looking good, to worry about getting an eye exam from there kind of through, um, childhood, like, uh, maybe early elementary school, unless they bet your baby is presenting with 1 of a number of features that parents often pick up on.

For example, as the baby's aging through those first couple of years, you know, through the first couple of years, babies actually don't have great visual acuity.

And so As they're aging over those first couple of years, it's normal for them to have roving eye movements, for example, be searching their environment.

But over those first couple of years, if parents start noticing the baby isn't making eye contact or looking where a sound is.

Certainly if they have what's called nystagmus, like these rapid, flickering, alternating eye movements.

Anything like that, of course, you're gonna trigger an eye exam, but otherwise, most babies, other than their pediatrician doing that red reflex check when they're in for their regular well child checks.

That's really all that's needed through that.

When most kids get to elementary school age, there'll often be, often done at the schools, an amblyopia screening exam.

If kids' eyes either, if 1 eye doesn't see that well, like maybe you're very near sighted or far sighted in 1 eye and pretty normal sighted in the other, or the 2 refractive errors are quite different from each other.

Um, that can lead to a condition you've talked about on the podcast before called amblyopia, which is probably 1 of the more common or most common eye diseases of children.

Or if the eyes aren't aligned, you know, our eye muscles and the brain behind them are really responsible for keeping the 2 eyes looking straight ahead.

And if that's not working properly, and 1 eye is off kilter, and therefore the image of what we're looking at is falling on different spots of the retina, it's not syncing up right in the brain, that can lead to this disease condition called amblyopia, where that eye is no longer talking to the brain properly.

And there's a pretty easy screening exam that can be done for strabismus, the misalignment of the eyes that kids will do in elementary school.

The other main presenting symptom of kids in elementary school is when they admit to their parents, I can't see the board or I can't see the teacher up front.

And then they might be quite nearsighted.

And so those are usually the parts for, for babies, for toddlers, for children, school-aged children that might reasonably trigger an exam.

A couple of questions about early eye exams, and we'll get on to eye exams in older individuals in a second.

But I want to interrupt you with this question.

So you mentioned that there can be a misalignment of the eyes.

I've seen many people's babies where there is 1 eyeball that seems to be kind of drifting around and then it might correct, but sometimes they'll have a, we don't wanna get technical here for our listeners, we'll keep it general, but either convergent eyes or one-eye converging, cross eyes or wall-eyed, you know, again, using that non-technical language here.

And My understanding is that the brain is taking that information in and is very plastic, it's changing in these early stages of development and that it's fairly critical to get that stuff corrected early on, because if you wait too long, the brain can essentially become blind to the...

Or rather the brain cannot learn to handle the proper alignment.

So in other words, if a kid has crossed eyes, and they're not corrected until their 20s, it's possible that they will never recover normal vision.

Whereas if you align the eyes properly early in development, they can indeed recover vision.

How early can and should 1 consider getting those eye realignments done?

What they'll do is if they detect any eye misalignment and sometimes parents are good at noticing that.

And sometimes you take a picture and 1 eye got the red eye reflex and the other 1 didn't.

And sometimes people notice that their kids' eyes are sort of turning in, it seems like too much.

Sometimes there's what's called pseudostrabismus, which is where actually depending on your anatomy, if you have a little extra skin sort of on the inside corners of your eyes, it makes your eyes look turned in when actually they're straight.

But if your eyes are actually turned in, or slightly less common in children, more common in adults, misalignment turned out, it's really important to correct that early.

And the reason is, as you were saying, the brain starts ignoring it.

It fails to fully develop the strong connections for the data coming in from 1 of those 2 eyes into the brain.

And if you pass certain sort of thresholds during development, during childhood, without correcting that connectivity, getting those 2 eyes to work together properly, you can permanently lose that.

And so we used to use very sort of gross numbers, like it's fully correctable if you can intervene before age 3.

It's partly correctable if you can intervene before age 6.

But it turns out in follow-on studies that even kids into their young teens have a shot at correcting that eye-brain connection, that amblyopia, that loss of vision that can occur during early development.

So even if you're only, you know, unfortunately detecting that later on in childhood or even sort of the tween years or early teen years, it's still worth a try to really push to retrain the weaker eye and then also realign the muscles so that they can work together to keep the eyes focused.

And there's a lot more to learn about brain plasticity and probably a lot of really cool new therapies yet to discover that could reopen what's called critical period plasticity, this plasticity that we have during development that kind of goes away as we age.

And that critical period plasticity, as you know, has been the best studied actually in the visual system.

And the idea that we could reopen that is really fantastic.

But for different parts of that eye-brain connection, there's different periods for critical period plasticity.

For example, even if you get the amblyopic eye to see well again, and then you realign the eyes and now they're working together.

A lot of kids will never recover full depth perception, stereopsis, the use of 2 eyes to see depth, for example.

So why that part of the brain doesn't correct as well as the visual acuity or central vision part of the brain.

I'm going to ask for a curbside consult as it's sometimes called right now by telling you a story.

When I was a kid, I went swimming without goggles and I had 1 eye closed and the other eye open and closing as it went in and out of the water because I'm a deficient swimmer and I only breathe to 1 side unless I really consciously force myself to breathe to both sides in a freestyle swim.

Got out of the pool and I was seeing double.

And then it became downright scary because I didn't recover my double vision until they patched 1 of the eyes, forcing me to use the other eye that had been closed the entire time.

And fortunately this was done early enough and I was young enough that within, I think it was about a day or so, I restored normal vision.

However, my depth perception is terrible.

I'm the kid that fly ball was hit to me in the outfield and it's coming and then it hit me.

This is why I've generally focused on foot sports throughout my entire life as opposed to precise hand-eye coordination.

I'm better at throwing darts and things with 1 eye closed than I ever would be with both eyes.

The question I have is, is it true that even just a few hours of misalignment of information to the 2 eyes early in development can permanently rewire the brain unless there are some corrective measures such as patching up 1 eye.

The example I gave is just 1, but for instance, if someone gets a scratch on their cornea and they patch the eye and the person happens to be 10 years old, is it important to then patch the other healthy eye after the scratched eye is feeling better?

In other words, how critical is it to ensure the balance of information coming into the 2 eyes, even on the order of hours or days?

Yeah, Your story has some features of totally usual, how we think about misaligned eyes leading to amblyopia where 1 eye is weaker, patching the strong eye so the weak eye can recover, but not necessarily fully regaining depth perception.

And so that part of it is quite stereotypical.

The part of your story that's atypical is that for most kids, an hour or 2, let alone minutes, an hour or 2, even an hour or 2 a day.

If you were, I don't know, if you were a young kid and you just really were training up on throwing darts and you were just keeping 1 eye closed to throw the darts, you know, really practicing for an hour a day, it'd be very unusual for that to trigger this kind of either strabismus misalignment of the eyes let alone amblyopia and the strabismus is what's giving you the double vision because they're misaligned let alone the amblyopia of 1 eye turning out weaker.

If I had to guess of course not having you know done your exam before that fateful day in the swimming pool, if I had to guess, I would guess that you may have had some intermittent strabismus and your brain was already getting kind of hit And neither you nor your parents may have even noticed it.

It could be happening at other times of day, or you're not kind of really paying attention.

It doesn't kind of stand out in the way that that day that you got out of the swimming pool, you really noticed it.

But if you had had some years of intermittent esotropia or turning in of the eyes or exotropia, turning out of the eyes that just happened here and there, but was accumulating sort of a damage or failure to connect over years leading up to that day in the swimming pool.

And that day just tipped you over the edge and you've got double vision.

That led to an eye exam at an eye care provider.

And they said, wait a second, this eye is stronger.

We're going to start patching your strong eyes so you can get your weak eye back.

So for 99.9% of the kids who like, you know, yeah, they get a little corneal scratch or they're patching 1 eye closed or, you know, anything that's sort of a rare event like that, nothing to worry about, parents don't have to worry, kids can be kids, They can play, they can do that kind of thing and, uh, and not have to worry.

And, and, and it's unfortunate that we can't tell in advance which kid's been having the intermittent amblyopia because we don't do a standard eye exam on every 5 year old who's not complaining of anything.

But yeah, so that's an unusual case in yours.

And if I had to guess, I would bet that you were having some sort of subclinical, untracked, uncharted, unnoticed, maybe strabismus leading up to that point.

So I was part of the generation that grew up with some computers in the classroom, but not a lot.

Nowadays, kids from a very young age are looking at iPads and phones and screens and things very close up.

And there is a wealth of experimental animal data showing that if you limit vision to just close range, that the eyeball lengthens and therefore the visual image falls in front of and not directly onto the neural retina, essentially the light sensing portion of the eye, and those animals become myopic or nearsighted.

What can we say about the environmental conditions in which kids are seen from the time they're born through, let's say, adolescence and their teen years in terms of how their visual system wires up.

And are there any recommendations that are coming from the scientific literature, clinical studies, clinical trials, excuse me, or otherwise that indicate what a healthy visual environment consists of?

And actually, it's really relevant these days because, you know, myopia is so common.

In California, we have a lot of Asian heritage or Asian-Americans.

And so we see a lot, like at Stanford, we see a lot of myopia in kids and adults.

And really starting to get thoughtful on the science of myopia control.

How do we provide the right environments?

Now what's interesting is that for decades, the assumption, some of the data really led us to the path of thinking like, gosh, the more you spend at near activities, and these are mouse model experiments like you described, but also well-designed human cohort studies, figuring out, asking kids and families, how long is your kid reading or in front of the computer?

Versus how much time is your kid in front of the computer doing near work?

And these well-designed cohort studies did point towards this concept that if you do too much near work as a kid that you're more likely to develop nearsightedness as you get through those sort of preteen and even into the teen years, which is when most of that myopia progression or eyeball elongation is actually happening to cause nearsightedness.

It's only been in the last few years that some really exciting studies have actually pointed in a slightly different direction and that's that maybe it's not all, not to say it's not about near activity, but maybe it's not all about near activity.

Maybe it's actually a little more about the kind of light we're getting into our eyes.

And I think you've talked about this before, and it's really important.

When they've now studied and asked the kids, instead of just how much near and how much far are you doing, how much time are you spending indoors in indoor lighting, which doesn't have full spectrum light in a typical indoor environment, versus how much time are you spending outdoors, playing in the yard?

You could be reading outside, but what kind of time are you spending outside?

And of course, when you're outside in sunlight, even if it's in direct sunlight, you're getting a different spectrum of kind of full spectrum lighting from the sun.

And it looks like it's pretty clear now, actually, that it has maybe more to do with outdoor lighting time than just near work.

And so I think that, you know, we've, we've actually already seen the first couple of randomized controlled trials where they're having kids intentionally spending time outdoors versus sort of standard life, which, you know, it's going to be often much more indoor time.

And and seeing some effects, you follow those kids over a couple of years.

And the kids who spend time outdoors are are progressing in their nearsightedness less like they're they're nearsighted.

Prescription is not getting as strong as the kids who are spending more time indoors.

And there's some pretty good biology that's getting worked out, going back to animal models, more about how that might be working in the retina, inside the eye.

And so, as a parent, you may want to be, you may want to be telling your kid like, okay, yeah, I want you to read that book or, you know, if your kids plan on the phone or something like that, or the iPad or something like that, they're allowed that time.

Okay, you can have that time, but I want you to spend some of the time that you're doing that outdoors.

Are there any thresholds for the amount of time that 1 would suggest their child be outdoors to get that full spectrum light?

You know, we talk about cohort studies where we just ask people, what are they doing?

And there seems to be, you know, a little bit of what we would call a dose dependent response.

Maybe the more time outdoors might be better.

We don't know if there's an upper limit, like, gosh, if you go over 2 or 3 hours, there's no additional benefit.

The real gold standard for answering these kinds of questions are randomized controlled trials, and specifically placebo-controlled, or a control group that's not getting the intervention.

That's our highest level of evidence for clinical evidence for any of this kind of science when we're talking about humans or preclinical models in the laboratory.

And the study that hasn't been done yet to really answer that question is to randomize kids to telling this group of kids, you just do your normal life.

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Dr. Jeffery Goldberg: How to Improve Your Eye Health & Offset Vision Loss