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Dr. Lloyd's blog has now been retired. We appreciate all the wisdom and support Dr. Lloyd has brought to the WebMD community throughout the years.

Tuesday, December 9, 2008

Shortest Days Approaching

I’m a calendar watcher.

Some folks are clock watchers, but I prefer a wider horizon. In my mind I’m frequently playing with days and dates. On the first day of each month I commit to memory on which day of the week the 7th, 14th, 21st, and 28th appear – they fall on Sundays this month. From there I can easily create a mental calendar.

I can’t say it helps my memory. It simply helps me track days and dates.

In my mind, for some reason, the summer solstice and winter solstice are important calendar mileposts. The winter solstice is just a few days away. It occurs at the instant when the sun’s position in the sky is at its greatest angular distance on the other side of the equatorial plane from the observer. Depending on astronomical shifts, winter solstice occurs some time between December 20 and December 23 each year in the northern hemisphere. (Trivia buffs: 7:04 a.m. ET, Sunday, December 21, 2008!) You recognize this as the date with the shortest daytime elapsing between sunrise and sunset.

Since childhood I have kept track of whether the days are getting longer (happy news) or shorter (gloomy news). Back then, winter solstice traditionally meant surviving grade school in an underheated building and summer solstice heralded a long vacation, although nowadays most schools close by late May.

For the past 15 years I have been in Maine when the summer solstice occurs. Combined with its northern latitude, daylight on this special day appears before 4am and persists until 10pm or so. It’s usually a mild June day with happy memories. Conversely, I am on a family ski vacation in late December when the sun makes an all too brief appearance atop the peaks. By 2pm long shadows have already formed that direct skiers to the waiting village below.

Maybe mood is actually linked to sun exposure – kinda gets you thinking.

With regards to good vision and astronomical phenomena, I’m far more concerned about the shorter winter days and the well-documented increased risk of bodily injury related to poor visibility. If you can’t see well you are more prone to trouble, and if others can’t see you then those same risks are magnified

Here are a few ways to make yourself more noticeable when outdoors this winter, whether it is clear, foggy, drizzly or snowing:

  • Wear bright colorful clothing when outdoors
  • Adhesive reflective tape will boost your visibility (any hardware store)
  • Wear large funny hats, especially in mall parking lots, so drivers can identify you
  • Apply clip-on lights to your apparel or headwear when you jog or bike (available at any sporting goods store)
  • Keep a supply of self-igniting flares in your car in case of emergency
  • Store an ultra-bright flashlight in your car
  • I also keep a lightweight ‘coal-miner’ headband lamp in my car for changing tires…keeps the hands free

My mother always encouraged me to blend-in with the crowd, “William, you don’t want to be too conspicuous.” Sorry, Mom, but when the days get this short it helps to stand out and be recognized…from a very far distance!

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Posted by: Bill Lloyd MD at 8:50 am

Friday, December 5, 2008

FDA Ponders Prescription for Luscious Lashes

Talk about your unintended consequences!

Back in 2001, shortly after the FDA approved marketing of the eyedrop bimatoprost (trade name Lumigan) for use in treating glaucoma, doctors and patients began noticing something very unusual.

Patients who used bimatoprost observed that their eyelashes were growing longer and more plentiful – males and females alike. The women were ecstatic! Besides providing effective control over elevated intraocular pressure, an unanticipated side effect was further boosting its popularity (and sales!)

This phenomenon was first reported during controlled placebo studies wherein one eye got bimatoprost and the fellow eye received the same eyedrop solution without the active ingredient. Yep, the bimatoprost eyes had lower pressures and lustrous lashes.

Now, drugmaker Allergan is ready to take it to the next level. Allergan has applied to the FDA for permission to sell the prescription eyedrop as a cosmetic treatment to enrich lashes.

So far the regulatory journey has been relatively smooth. A randomized study involving 278 volunteers proved that bimatoprost was a safe and effective way to enhance eyelash appearance. No serious adverse events were reported.

Cosmetic bimatoprost (sold under the brand name Latisse) will be applied directly to the upper eyelids only – not plopped into the eye like its predecessor. True, if Latisse gets into the eye the intraocular pressure may temporarily go down a few points but there are very few patients (clearly identified) for whom this may cause problems.

This isn’t the first time Allergan has successfully identified new uses (and new revenue streams) for its products. Ever hear of Botox? Eye doctors were the first to use Botox to weaken overacting eye muscles and to quiet blepharospasm. Then Allergan found a profitable new wrinkle for the drug!

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Posted by: Bill Lloyd MD at 3:07 pm

Wednesday, December 3, 2008

Can YOU See in 3-D?

3-D movies are making a comeback in a big way.

Earlier this year Brendan Fraser produced and starred in a remake of ‘Journey to the Center of the Earth’. A special version screened in 3-D at IMAX theaters and was instantly declared, “The best and most spectacular 3-D movie ever made”. Nice buzz. (Personal note: Last week I got to see this film on a 5 inch screen while flying across the country. Can’t say I was nearly as impressed with it in tiny 2-D!)

Now the Disney animators are taking a shot at 3-D with their new release “Bolt”.

So, how do the eyes see in 3-D? Can you see in 3-D?

First of all, 3-D is a manmade construct. Think of it as a marketing term to describe the visual mechanics of stereopsis. The total visual input into each eye is different. Stereopsis is the product of integrating what the two (different) eyes see.

You really need both eyes to appreciate stereopsis because it represents the DIFFERENCE between what the two eyes are seeing…a microscopic difference. For example, those tossaway 3-D specs have different colored lenses (often red/green) to project the image at different areas of the retina. The goggles INTENSIFY the difference between what the two eyes experience. Guess what? Even if you are colorblind the 3-D specs should still work!

Don’t confuse 3-D with depth perception. Depth perception helps you pick the best apple in the basket on your first attempt. Many people with ONE EYE exhibit excellent depth perception. Subtle components to the visual image (color, texture, shading, shadows, and more) communicate to the visual cortex (in the brain) not only WHAT the object is, but its position with relationship to other elements of that same image.

I have had patients who underwent surgical removal of one eye for various reasons. Some (not all) of these people could still pass the tests for stereo vision, depth perception and distance estimation. Perhaps some of these skills are LEARNED…you get better over time. To date there are no hard scientific explanations to account for this not-uncommon phenomenon.

The holidays offer plenty of time to take in a movie. If your children choose to go see ‘Bolt’ in 3-D (which means you will be attending the movie as well) take time to experiment with the screen images – cover one eye, etc. and share your 3-D experience with us over at our WebMD Vision & Eye Disorders message board.

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Posted by: Bill Lloyd MD at 1:35 am

Tuesday, November 18, 2008

When Things Appear Clear but Different

Sometimes it can be very difficult for a person to describe something like a visual symptom.

“…it’s kinda green and it looks like it is on fire”

“…I see a repeat image but it begins 30 seconds afterwords”

“…think of it like a bright halo with a big upside-down X in the middle” (hey, isn’t an upside-down X still an X?)

Having practiced medicine for nearly 30 years I have witnessed many valiant attempts. Fortunately, most of the time, there is a nondangerous explanation to describe whatever the patient saw. On the other hand, specific symptoms are highly informative clues to the eye doctor.

“…my right eye just sees things differently than the left eye”. Such a disclosure may indicate a genuine problem.

Take a look at the top picture of colorful fall foliage. The vibrant colors jump out of the top photo. Imagine seeing that image with your left eye, but after covering the left eye the image in the right eye resembles the bottom picture. It’s still clear, the image is still crisp, but the colors appear washed-out. The medical term for this change is color desaturation. Acquired color desaturation often signals a problem in the affected eye or in the attached optic nerve. Here’s some comfort, a brain problem would not preferentially cause one-sided color desaturation.

Such a great disparity between the two eyes may not be noticed unless one eye is temporarily covered – like during an eye exam. There are some simple, painless clinic tests that can evaluate color desaturation complaints. Remember, the cause is likely inside the affected eyeball or its optic nerve. Cataract, for example, commonly causes this symptom and its presence is easy to confirm.

If the retina or optic nerve is the culprit then it is likely that other vision tests will be similarly abnormal. The penlight test of pupil behavior is a great example. A person with color desaturation due to an optic nerve problem like undiagnosed glaucoma will also demonstrate an abnormal pupil response to a swinging penlight test. On the other hand, if the pupils behave normally then the cause is localized to the eyeball and likely a fixable problem.

Here’s what you should know:

  • It’s a good idea to check the vision in each eye separately every so often
  • See your eye doctor if you sense color desaturation in one eye
  • Don’t give up if the first eye doctor cannot explain your unusual symptoms. Consider letting a second specialist listen to your story.

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Posted by: Bill Lloyd MD at 3:55 pm

Monday, November 17, 2008

Next Millennium Drug Delivery

Drug researchers have a lot to consider when they create new medical treatments. Besides chemical formulation, bioavailability and potential adverse effects, these scientists also want to optimize the delivery of the new drug to where it is needed most.

The eye is a particular challenge because eyedrops don’t simply migrate across the clear cornea and enter the eye – although at times we wish they could! If this were the case the eye would double in size everytime we swam underwater without goggles!

A variety of biochemical barriers and microscopic membranes interfere with direct drug transport. Clever drug researchers invented eyedrop formulations that allowed the medicine to alter its identity (electrical charge, lipid and water affinity, and pH) as the compounds make their way across the cornea.

When eye specialists needed a way to deliver high doses of antiviral medication to people with CMV retinitis (a blinding eye infection) inventors created tiny drug wafers that could be surgically implanted deep inside the eyeball. Some intravenous drugs are inert until stimulated by infrared, microwave or RF energy that is externally applied to the target organ. Again, put the drug where its needed.

Other medical specialists grapple with similar challenges. Powerful drugs used to treat colon cancer or severe intestinal inflammation can make people very sick as the drug circulates throughout the bloodstream. A team at the Dutch electronics conglomerate Philips has unveiled the intelligent pill – the iPill. Think of the iPill as a robot dumptruck with a built-in cellphone. It has its own wireless transmitter and measures 1.0 by 0.5 inches (bigger than a ‘Mike & Ike’ candy) and it cannot be chewed!

Gulp! Once it is on its way the iPill broadcasts the acidity of the surrounding contents. Since acidity drops as intestinal contents travel south of the stomach this is an accurate way to map its location. I don’t think consumer-grade GPS gear is that precise yet but I’m sure NASA is already working on it.

Once the iPill is at the desired location (duodenum, ileum, acsending colon, transverse colon, descending colon) it electronically releases the perfect dose of the prescribed medication. The rest of the body is unaffected. With traditional medicines you may need to consume 500mg in order to get 50mg to reach the target organ. The rest of the body has to deal with the leftovers!

Okay, I know what you’re thinking: how much will it cost? The prototype versions run $1000 per iPill (equivalent to 4 iPods!) Over time, like all electronic gadgets, the price will drop significantly…perhaps down to $10 per swallow. In the meantime I just hope Philips does not license the technology to Apple!

Okay, okay, I know what you are really thinking: what happens to the iPill once the journey is complete? It enters the iToilet and heads for the iSewer. Folks are already concerned that there is too much excreted Prozac in our drinking water, what happens when thousands (or millions of Americans start swallowing iPills? The iPill team at Philips says they don’t have a good answer yet. For now they are still working on a solution. I’m not too worried. Having seen all of the bizarre things my children have accidentally dropped in the potty I’ve never seen them reappear from my kitchen faucet.

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Posted by: Bill Lloyd MD at 3:29 pm

Tuesday, November 11, 2008

Permanently Pain-Free…Feel Good to You?

Scratches, abrasions and other very superficial injuries to the clear cornea often feel worse than a gunshot wound: super intense, burning, boring discomfort. It often persists even after the eyelids close.

There is a complex layer of sensory nerves that serve the outer cornea. These tiny nerves reside right beneath the epithelial cells and are immediately exposed following any trauma to those outer protective cells. These same nerves activate the instantaneous blink reflex whenever anything approaches our eyeballs, slamming those eyelids closed like a bank vault.

Fortunately, since the nerves are so close to the surface they are very accessible to topical anesthetics. These eyedrops temporarily block the sensory fibers’ ability to conduct a pain signal back to the brain – the problem is still there, your brain just doesn’t get the word.

Attention medical history buffs: Topical anesthetics (drugs like novocaine, lidocaine and tetracaine) derive from the same chemical family as cocaine. In fact, the first reported legitimate medical use for cocaine was for performing eye surgery over a century ago. A lot of history articles depict an oral surgery procedure but the scientist behind topical local anesthesia was Dr. Karl Koller, an Austrian ophthalmologist.

Since these eyedrops numb the pain why not prescribe them for continuous use until the patient recovers? There are several wise reasons that condemn that practice.

Pain is useful to the clinician. If the patient’s symptoms persist the doctor may want to explore other diagnostic possibilities. Pain relief also signals clinical improvement.

There is no guarantee the patient will return. Why should they? Their pain is gone, at least until they run out of eyedrops. In the meantime an abrasion may become an infected ulcer and permanent visual loss may result.

Topical anesthetics can inhibit healing. Additionally, chronic use of topical anesthetic eyedrops is toxic to the eye and can lead to irreversible corneal changes.

For these reasons eye doctors do not usually dispense topical anesthetics to their patients. A comfortable eye patch with a generous amount of ointment will usually work. Savvy, suffering patients may attempt to swipe a bottle of topical anesthetic when nobody is looking. Yes, this happens all the time.

Remember, ignorance is not bliss and anesthesia is not a treatment. Numbing the cornea does little to heal the underlying problem and, in some cases, actually creates new problems.

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Posted by: Bill Lloyd MD at 4:31 pm

Tuesday, November 4, 2008

How Does Squinting Improve Eyesight?

A recent visitor to our WebMD Vision & Eye Disorder message board posted an inquiry about his mother who had just recently had cataract surgery. I could immediately sense the worry in his posting.

During the post-op clinic visit the woman could see very the vision chart very clearly when using the familiar pinhole occluder. It uses a movable plastic flap with lots of small holes. Once the pinholes were removed the woman’s vision was very blurry. Was there cause for concern? I was able to offer some much-needed reassurance.

As I teach ophthalmology residents, the answer to every question regarding the eyes and vision is based entirely on either anatomy or optics – sometimes both!

The pinhole occluder imitates the most precise pair of eyeglasses ever made. The individual pinholes (Trivia Alert! Each hole is 1.2mm in diameter!) only permit straight rays of light to pass through. Therefore, only straight light rays enter the eye.

The optics of corrective spectacles work to straighten bent light rays – to reverse a refractive error. Now, if the rays are already straight no refracting is necessary. This explains why folks often see better when using the pinhole occluder (with or without their eyeglasses). People who can already see 20/20 without correction do not experience any improvement with the pinhole. A person with spectacles who sees better with the pinhole likely needs a change to their correction. In the case of the post-op cataract patient, she can expect an excellent visual result once healing is complete and postoperative astigmatism resolves.

Can you make a pinhole occluder at home? Sure! Unbend a standard paper clip and use one end of the wire to poke multiple holes in a index card – perhaps one-quarter inch apart. When you peek through the pinhole you should be able to read the time on a clock across the room.

We instinctively create a pinhole every time we squint. By narrowing the opening through which light can enter the eye we eliminate many nonaxial (not straight) light rays.

Pinholes and squinting are not a long-term solution for improved vision. They markedly constrict the visual field and reduce total illumination. Even so, both help us see better until our refractive errors can be corrected.

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Posted by: Bill Lloyd MD at 11:43 am

Monday, October 27, 2008

Med School: What’s in a Name?

There are 126 medical school in the United States and every one of them has a name. Most of the time the medical school name name is derived from the parent university. The medical school is just one of several ‘tenant colleges’ within the larger institution: business school, law school, veterinary school, etc. The Ohio State University College of Medicine is one such example.

There are 19 USA medical schools which have been named (or renamed) as the result of a gift, such at the Feinberg School of Medicine at Northwestern University. In 2002 a $75M donation made it all happen. Back in 1941 Wake Forest University cut the ribbon on Bowman Gray School of Medicine after a $750,000 act of philanthropy. 58 years later it was redubbed Wake Forest University School of Medicine to distance Wake Forest from Bowman Gray, the former president of R.J. Reynolds Tobacco Company. Change happens!

In the past decade alone there have been 10 renamed medical schools. The two largest transactions were for $200M each: UCLA’s David Geffen School of Medicine and New York’s Weill Cornell Medical College. I imagine the family members of these namesakes enjoy prompt appointments and convenient parking. Not jealous, mind you, just an observation.

Not every proposed cash branding deal makes it to the sign shop. The School of Public Health at the University of Iowa politely declined a $15M offer from for-profit health insurer Wellmark because of perceived ethical conflicts. Child advocates successfully blocked provocative teen apparel retailer Abercrombie & Fitch from staking out the emergency center at the Children’s Hospital in Columbus, Ohio. Their angry protest lamented, “Given the company’s appalling history of targeting children with sexualized marketing and clothing, no public health institution should be advertising Abercrombie & Fitch.” You know something? I’ve seen the A&F; ads in the magazines and those buff models wear practically nothing…where’s the merchandise anyway?

Authors commenting in a recent JAMA editorial worry that corporate branding of medical institutions may confuse health consumers and lead to misinformed choices. Probably so – I don’t think I could force myself to visit a doctor at the Coors Light Medical Center because I’m a Budweiser kind of guy. All kidding aside, state legislatures and taxpayers may revolt if they discover that public corporations are willing to fund highly visible health resources. Right now medical schools don’t need any new reasons to discourage critical government support for research and patient care.

Do any of these practices bother you? I would like to know.

SOURCE: JAMA, October 22, 2008, pages 1937-1938.

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Posted by: Bill Lloyd MD at 11:14 am

Sunday, October 19, 2008

Don’t Give Me the Flu

Here’s a sincere plea: Don’t give me the flu!

You see, if I contract viral influenza I will very likely give it to many other people. For up to five days before I develop fever and realize that I’m sick, I will shed highly-infectious virus particles to everyone with whom I come in contact. Earlier this week I was in a very crowded lecture hall with over 200 people who came to hear me speak. Did you know that I roam all over the room when I lecture? Hopefully they departed with some useful information, a few laughs and nothing more.

Here’s the deal: You can protect me if you get your flu vaccination.

Are you worried about availability? There are over 135,000,000 vaccine doses available today.

Are you worried about Thimerosal? You shouldn’t be worried because there is no valid scientific evidence that links Thimerosal to neurodevlopmental disorders. But lets say that you are still skeptical. Many flu vaccines are Thimeosal-free… all you have to do is ask. Single-dose syringes and the nasal FluMist influenza vaccine contain no Thimerosal.

Thank you for protecting me from getting influenza.

Be sure to get your healthy children over 6-months-old vaccinated, too. Children love me and they flock to me. School-age children are also very powerful vectors for influenza. They can shed live virus for 10 days because of their younger immune systems. Remember, I asked for your help.

[youtube=http://www.youtube.com/watch?v=Kh_6X6C2Icc]

Worried about needles? By now I hope you would be willing to take one for me, but even the squeamish can still be heroes. The FluMist nasal influenza vaccine is inhaled through each nostril and works just as well as the injectable form. In some aspects FluMist is superior to the traditional injection.

Finally, if I get the flu, I will likely miss work and be unavailable to help all those who are counting on me. This will really mess things up. So, please keep your promise and go get your flu vaccine.

On second thought, I’m not sure you’ll keep your word. I’m going to go get myself vaccinated. That way I can help protect you and your family from seasonal flu.

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Posted by: Bill Lloyd MD at 12:55 pm

Monday, October 13, 2008

Consider Yourself a Gym Rat?

Photo Credit: Thang Nguyen

How often do you workout?

Daily? Weekly? Seasonally?

Folks who head to the fitness club frequently are called gym rats. These athletes feel the burn every day – sometimes twice a day, yikes! I consider myself a gym mouse…maybe a gym gerbil. I try to find 45 minutes every every day for some exercise, alternating between running outdoors and moderate weight training.

A recent visitor to our WebMD Vision & Eye Disorder message board asked about eye irritation that was only experienced while exercising at the gym. I mentioned some possible culprits, but it got me thinking about how potentially hazardous fitness centers can be to the eyes. The more I thought about it the longer my list grew.

This blog was not posted to generate alarm or to discourage readers who want to become gym rats (or gym gerbils!). I just want to share some practical ideas regarding vision protection when exercising at a fitness facility.

  • Protective goggles + racquet sports: ‘Nuff said. Choose a durable polycarbonate product. Stay away from the ‘lensless’ goggles because the deformable, high-speed ball can still strike the eyeball.
  • Protective goggles + tanning booths: ‘Nuff said again. Tanning booths are unsafe but it’s hard to get some people to turn away. At the least they should shield their eyeballs.
  • Extreme weightlifting: Do not strain when handling barbells – keep breathing. The blood pressure skyrockets during heavy lifting…systolic readings often exceed 400mmHg (more than 3 times normal). Delicate retinal blood vessels can burst and wipe out your eyesight for months.
  • Swimming pools: Chlorine can make eyes red, but abnormal pool water pH is more likely to cause discomfort and blurriness due to superficial corneal edema.
  • Spas/Hot tubs: Stay away if you have had LASIK or if you are wearing contact lenses. Your cornea is like a culture plate just waiting for some germ to visit…like Acanthamoeba.
  • Stretch cords/PT straps and other elastic devices have a bad reputation for snapping back at your face. Also, put some space between you and other customers.
  • Physical contact: Don’t share towels and always wipe down apparatus before and after use. Other athletes are continuously coating the health clubs with their own germs. Protect yourself from unwanted colds and pinkeye.

What about yoga? I don’t know any eye hazards with yoga. How could you hurt your eyes in a Happy Baby pose?

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Posted by: Bill Lloyd MD at 12:01 pm

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