Dressed in a teal sterile surgeon uniform, Thiran Jayasundera holds microscissors with latex gloves. Sitting, he leans in to stare through a microscope-like lens aimed straight down over a patient’s eye. Backaches. Bright lights. For four-and-a-half-hours, Jayasundera painstakingly places and attaches the prize his patient has waited years to receive–a $150,000 (Medicare-covered) computer chip just three by five millimeters–scarcely larger than this: ▦
His peers are, or will be, watching; the surgery is being shown live on a screen just outside of his Kellogg Eye Center operating room and is being recorded to teach other surgeons. This January 2014 operation, and a second the following week, mark the first commercial implantation of “bionic eyes” in the United States.
The operations marked a milestone in treating patients blinded by an eye disease called retinitis pigmentosa, a genetic disease affecting 100,000 Americans. It often shows up later in adulthood and causes cells in the retina–the back of the eye where images are sensed–to gradually die.
That’s where the Argus II implant comes in. The tiny patch of wires connects to a slightly larger electronics case implanted just outside the eye. The case receives information wirelessly from a camera mounted on special sunglasses the patient wears. The visual information is transformed into electrical impulses that directly stimulate the remaining retinal cells.
This implant won’t help all patients, but for those with advanced disease, who have no useful vision, it can give some sight back. That’s what it did for Roger Pontz, the fifty-five-year-old Reed City man who at Kellogg in January became the second patient to receive the commercial implant.
Pontz heard of the implant when it was still being tested four or five years ago. “The minute it got approved [by the FDA in February 2013], I called,” he says.
Jayasundera pushed his team to connect with California-based Second Sight, the company that developed the Argus II, and Kellogg was approved as one of the first twelve facilities to offer the surgery when it became commercially available in January. Jayasundera says that Kellogg offered Second Sight a “well-oiled machine for retinal [care]” with a team-oriented approach and a large staff with wide specialties.
Doctors like Jayasundera usually see patients or perform surgeries, but he does both. “There are maybe two other people in the country that do what I do–both retinal dystrophies and retinal surgery,” he says.
But Pontz, like all Argus patients, needed more than just the surgery in order to see; he needed testing and around three months of training to learn anew how to see. First, his doctors had to wait to turn the camera on and make sure that the device wasn’t going to make the light he saw too bright. They told him that he might not see anything that first day. Then they flicked the switch on the little black power box at his side and turned the lights in the room on and off.
“That’s a flash!” he recalls saying. “I’m sitting there thinking, ‘Am I dreaming? Am I hoping?'”
Even though he can’t see the way he could when he was young, Pontz could tell the difference. He sees in black and white with shadows of lightness and darkness, not in color or with details of faces. He can recognize the shape of a doorway, the contrast between a road and its surroundings, or a moving object–though he has to use the context to figure out what he is really seeing with his new eye.
Pontz, who works as a dishwasher, does not use his camera at work for fear of getting it wet, but it has helped him remedy some of his most basic deficits. As his sight failed, he’d adjusted to giving up driving, but bumping into walls still frustrated him.
“Before I had the Argus II implant, I would have to put my hands out in front of me … [now] I can go through the house,” he says. “I can see my dark plate on a white table. I can pick out cups on the table.”
He can even tell when his grandson runs into the kitchen. “That’s awesome. It’s just a great feeling.”
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When Jayasundera was training to be a doctor, there was no help for patients like Pontz. He says he went into his field because “things need to be done for them.”
Jayasundera, thirty-nine, has journeyed around the world to get to Kellogg. He was born in Sri Lanka, and when he was thirteen, his family moved to Auckland, New Zealand. As he finished his medical residency at the University of Auckland, he met Shalini Gunawardane at a wedding in California. They eventually married and lived in New Zealand until a genetics fellowship at the U-M gave them their first taste of Ann Arbor. Canada stole them for a two-year retinal surgery fellowship before Jayasundera returned to Ann Arbor as a faculty member in 2011.
The couple has two sons, one four, the other born this past June. That, and the new surgery, have kept him busy. Meditation and family time help him manage the stress. He calls his parents in New Zealand daily, and Gunawardane says he is never happier than when lying on the floor with their older son, “doing Legos and building castles and blocks.”
“My philosophy is you really do want to change the world,” Jayasundera says. “You do want to change the way we practice medicine somehow.”
His boss says that’s just what he’s doing. Jayasundera “is very innovative, dedicated, and has the gift of being able to … take something from a concept or an idea to making it happen,” says Kellogg director Paul Lee.
Like any surgery, it is not without its dangers. Because it’s a novel procedure, Jayasundera had to be trained to implant the Argus device. While it becomes more routine every time, to date only about ten people have received the implant across the country–four of whom are Jayasundera’s patients.
Pontz has to wear safety glasses for the rest of his life to protect his bionic eye, and faced the risk of infection, a detached retina, or losing his eye.
“But what do [I] have to lose?” he says.
After the surgery, his eye was uncomfortable and looked a bit swollen. It turned out the wireless receiver was pushing his eye out a bit. Jayasundera operated again to fix that.
The Argus II surgery is not the only treatment developing for patients with retinitis pigmentosa, but it is the first to achieve FDA approval. Other therapies aim to do one of three things: slow the progression of the disease, correct the genetic hiccups that cause it, or make new eye cells using stem cells.
Robert Weinreb, director of the Shiley Eye Center at the University of California-San Diego, says that it “is not clear yet” which treatment will “be most successful in clinical practice.” The techniques are too new, and are still improving. Future versions of the Argus implant, for example, should allow patients to identify colors and distinguish between faces.
In fact, one treatment may not be superior to another, according to Weinreb’s colleague Kang Zhang. Rather, “they are complementary,” says Zhang, who researches the gene and stem cell treatments. Those may be best for patients still progressing with the disease, while the Argus implant may be best for late-stage patients with no vision.
For Roger Pontz, it has been. And he’s urged his sister, who also has retinitis pigmentosa, to get in line for the implant. “There’s four kids, and three of us have it,” he says.
They may all end up visiting Jayasundera.
“For patients who have no vision,” Jayasundera says, “being able to have some vision is a great gift.”
