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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.

Wednesday, June 25, 2008

Your LASIK is Perfect, Here Are Your New Glasses!

Advances in technology and surgical technique (but mostly technology!) have led to very successful, predictable LASIK outcomes in appropriate surgery candidates. It can truly be the right operation for the right person.

Two areas of LASIK that deserves more attention are patient counseling and clear communication.

One huge misunderstanding experienced by all LASIK candidates is that they will never need to wear eyeglasses or contacts ever again. That statement is very inaccurate.

Truth be told, most LASIK patients will need glasses later in life. Here’s why:

  • The LASIK procedure may not fully correct the preoperative refractive error. This is common for extremely nearsighted (myopic) folks. LASIK will, however, convert them to thinner, lighter eyewear.
  • Perfect LASIK throws you into the swimming pool with all emmetropes (folks needing zero correction at distance). This sounds great but there’s a catch. Around age 40 emmetropes begin to experience symptoms caused by age-related loss of near focusing (presbyopia).
  • The LASIK procedure may generate imperfect results. Residual (or new) amounts of refractive error may require post-op correction.

In all fairness, some of these outcomes can be managed with more LASIK at a later time. Adults over 40 may opt for LASIK distance correction in one eye and LASIK near correction in the fellow eye – a strategy called monovision.

The important point to remember is that if you seek LASIK to eliminate eyeglasses or contacts make sure you and your surgeon share common expectations. Surprises are best reserved for wedding engagements and birthdays.

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Posted by: Bill Lloyd MD at 1:20 pm

Tuesday, June 17, 2008

Why Rx Meds Don’t Work

Americans are definitely living in the ‘Land of Plenty’. Most of us have access to some kind of health care and we can usually acquire whatever medications are prescribed:

  • Families enrolled in employee-sponsored health coverage usually pay a modest co-pay.
  • Many folks who agree to take generic meds get a discount or they can skip the co-pay altogether.
  • Low income families receiving Medicaid assistance pay very little, if anything, for their prescriptions.
  • Elderly beneficiaries enrolled in Medicare Part D enjoy the convenience of having their pills mailed to them.
  • Volunteers participating in clinical research get their medication for free and get paid to consume it!
  • Depending on circumstances, financially strapped individuals can directly contact drug makers to receive complimentary medications.

So, given all of these options (and many, many more) Americans still have a problem getting well. The problem has been identified and it does not involve flawed formulas, inaccurate dosages, mislabeling, or other critical lapses in the pharmaceutical pipeline. It appears that people don’t get better simply because they do not take their medicines as originally prescribed. The precise term for the problem is poor compliance.

Got any leftover pills in your medicine cabinet? Beware, you are part of the poor compliance problem.

Up to 70% of all medication-related USA hospitalizations are due to poor compliance, and that generates approximately $100 billion each year in added health care costs.

Prescriptions for acute problems fare best. Many folks will complete a 5-day pack of Azithromycin. 10 days of amoxicillin is a different story. Again, look in your medicine cabinet.

Now stretch it out for chronic health problems like high blood pressure and patient compliance really slides. More than half of all hypertensives fail to take all their daily meds as directed.

In ophthalmology we encounter the same phenomenon in chronic glaucoma patients. They don’t want to go blind but it can be very complicated managing three different eyedrops with three different schedules. Here’s a common situation:

Eyedrop #1: Apply twice a day to both eyes twelve hours apart

Eyedrop #2: Apply every morning but not at the same time as Eyedrop #1

Eyedrop #3: Apply every eight hours to the right eye only

Remember, this hypothetical glaucoma patient may have other additional prescribed medications to take as well.

The problem with poor compliance was recently highlighted in a large clinical study involving prescribed vitamin usage in patients with age-related macular degeneration. In an earlier WebMD blog we have discussed the Age-Related Eye Disease Study (AREDS) and the role of vitamins and antioxidants to slow progression of age-related macular degeneration.

After analyzing the compliance behavior of 332 adult patients consuming an AREDS formula, it was determined that more than one-third were not using them as prescribed – or not at all!

It was former Surgeon General C. Everett Koop who said it best: Drugs don’t work in patients who don’t take them.

Having problems keeping your medications on track? Why not put all of your drug bottles into one bag and schedule an appointment with your doctor to sort things out. They won’t do any good collecting dust in your medicine cabinet!

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Posted by: Bill Lloyd MD at 11:19 am

Friday, June 13, 2008

Fish Tale: Omega-3 Fatty Acid and Macular Degeneration

Few nutritional supplements carry the sex appeal of Omega-3 fatty acid (O3FA). It pops up everywhere and food marketers are harnessing its popularity to sell everything from butter substitutes to frozen seafood.

O3FA is a powerful antioxidant. It protects cells from free radical damage caused by aging, sunlight, and other environmental exposures.

Humans cannot synthesize O3FA so it must be consumed in our foods and supplements. For that reason O3FA is considered an essential fatty acid.

For many years eye doctors have encouraged their patients to consume lots of O3FA to protect themselves from Age-Related Macular Degeneration (ARMD) – the leading cause of severe vision loss in the elderly. In theory it made sense, but was there any scientific proof?

A new report published in Archives of Ophthalmology searched for proof. They analyzed over 2754 published articles on the subject and selected papers that met the authors’ specific criteria:

  1. clear definition of exposure (dietary or supplemental O3FA and fish intake),
  2. clear definition of AMD,
  3. appropriate statistical techniques adjusting for key confounders (eg, age and cigarette smoking), and
  4. estimates of odds ratios (ORs), relative risks, or the primary data to calculate these ratios.

Out of 2754 papers a grand total of 9 qualified!

Statisticians were able to combine the data from these 9 studies into one big database, a valid method called meta-analysis.

Long story short: According to the meta-analysis, ingestion of foods rich in O3FA lowered an individual’s risk for developing advanced ARMD by 38%! Oily fish like tuna, sardines, salmon and trout are the most readily available natural dietary sources for O3FA. It can also be consumed as a daily oral supplement, whether added to foods (butter substitutes) or in capsule form.

Weekend meal plans? How about a fresh trout fish fry along with french fries deep-fried in a O3FA oil? Pass the ketchup, please!

REFERENCE: Archives of Ophthalmology, June 2008, pages 826-833

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Posted by: Bill Lloyd MD at 8:14 pm

Monday, June 9, 2008

Beyond Joints: Eye Dangers in Rheumatoid Arthritis

Dry eyes are a common topic of discussion over at our WebMD Eye & Vision Disorder member community.

Most folks with dry eyes experience symptoms because of inadequate maintenance wetting of the eyes. Tiny accessory lacrimal glands near the eyeball produce these maintenance tears. Tear supplements and topical cyclosporine eyedrops provide effective relief.

Individuals suffering from Rheumatoid Arthritis (RA) are not so lucky. They have a serious autoimmune disorder wherein their own lymphocytes are targeting their own tissues. RA can lead to complete obliteration of all lacrimal gland tissue with consequent permanent eye damage. Imagine, not only do you lose flexibility and mobility in your joints you may also lose precious eyesight. RA is one diagnosis not to be taken lightly!

New research data recently published in the Journal of Rheumatology highlight these dangers. Nearly 13,000 RA patients were analyzed. 29% of these patients experienced symptomatic dryness of the eyes and mouth. All other RA symptoms were reviewed and compared to the dry eye statistics. This would include complaints like joint pain, fatigue, fever, etc. Guess what? The researchers discovered a very strong, reproducible correlation between combined RA symptoms of fatigue and body pain to the presence of dry eyes.

How is that information helpful? Individuals with early clinical dry eyes are not overwhelmed by dry eye irritation even though the microscopic damage is well underway. Patients often delay seeking care for their dry eyes until the tissue damage is at a more advanced statge. Early medical intervention to arrest the RA-associated damage to the lacrimal glands may preserve healthy moisture levels to the ocular surface and protect the eyes from long-term damage.

Here’s the bottom line: Folks diagnosed with RA who experience fatigue combined with body pain ought to seek referral to an experienced ophthalmologist for a complete dry eye evaluation. That should be easy to accomplish. Most rheumatologists (RA specialists) already collaborate with local ophthalmologists because of the required retinal screening for RA patients taking the drug Plaquenil.

Successful RA care requires aggressive management in order to protect the joints and the eyes.

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Posted by: Bill Lloyd MD at 3:10 pm

Wednesday, June 4, 2008

FDA to Explore Hazards of Contact Lenses

Less than two months after the FDA conducted public hearings regarding LASIK laser refractive surgery, the agency now wants to reconvene and explore another vital patient safety issue: contact lenses.

FDA’s Ophthalmic Devices Panel originally spent a full day listening to dissatisfied postop patients and expert LASIK surgeons. The panel has announced several recommendations for consideration by the FDA.

For the past two years contact lens wearers have had a worrisome time. First there was an outbreak of a dangerous corneal infection caused by Acanthamoeba species. Corneal ulcers caused by Acanthamoeba are very difficult to treat and can lead to loss of the entire eye. The problem was first reported in Chicago but similar outbreaks were reported in other cities as well. Several months later there was a worldwide product recall regarding a specific brand of contact lens solution that was associated with many (not all) of the Acanthamoeba infections.

FDA will convene the Ophthalmic Devices Panel on June 10 to discuss general issues with various lens cleaners and whether new testing or package labeling should be required, according to a notice posted on the agency’s Web site.

FDA will discuss developing testing methods to investigate the efficacy of multipurpose contact lens solution under “real-world” conditions. During the Acanthamoeba outbreak, some physicians suggested that the agency hadn’t thoroughly tested the contact lens solutions under the conditions in which many patients actually use them.

Others have theorized that unclean water played a role in the outbreak. The timing of the Chicago outbreak coincided with changes in the city’s water filtration system. Earlier outbreaks in Iowa and in Britain were linked to flooding and rooftop cisterns, respectively. FDA is also considering water sterilization data collected by the Centers for Disease Control and Prevention.

The information FDA collected from patients during the Acanthamoeba outbreaks suggests that many don’t know how to properly clean their contact lenses. Patients have gotten so comfortable with contact lenses that they don’t clean them properly and don’t read package labeling.

As a reminder, be sure to remove your contact lenses before swimming, before participating in water sports, using hot tubs, and even before showering. Contact lens wearers also need to remember to always “rub and rinse” lenses before storage to safely remove germs.

Adapted from a news release issued by the American Academy of Ophthalmology.

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Posted by: Bill Lloyd MD at 8:22 am

Monday, June 2, 2008

Kennedy: Wide-Awake Brain Surgery

YIKES! Was there a typo in the headline? Did it really read ‘Wide-Awake Brain Surgery’?!?

Warning: This is your last chance to click-away if you are squeamish!

Senator Edward M. Kennedy has undergone successful surgery at Duke University Medical Center to remove a malignant brain tumor. More precisely, the tumor was resected or debulked – not every bit was removed. Click here to read a recent WebMD blog about the Senator’s situation.

Many people were surprised to learn from the neurosurgeon that Senator Kennedy was awake during portions of the surgery. Two questions immediately come to mind:

  1. How could he be awake for brain surgery?
  2. Why does he need to be awake?

Many readers have been awake during knee surgery or caesarian section because anesthesia was selectively applied to the limb or the spinal cord. The injected anesthetic blocked all nerve function downstream from where the drug was applied. This technique doesn’t work for the brain because such an injection would shut down the heart, lungs and other vital organs.

In order to perform ‘awake brain surgery‘ the patient is sedated with a powerful, rapidly acting IV drug. Zonk! Out like a light! The patient’s head is positioned and stabilized in a very snug way (enough said!)

The surgeons then use a syringe and needle to inject all of the soft tissues (skin, subcutaneous connective tissues, and periosteum) in the region of the scalp where surgery will be performed. The patient is asleep so they feel nothing! All three of these layers have delicate sensory (pain) fibers. The infiltration of long-acting local anesthetic completely numbs the area. Skin incisions and opening of the skull bone (craniotomy) are performed. There are no pain fibers in the brain tissue itself.

Guided by previous MRI scans the neurosurgeons dissect to the area inside the skull where the tumor is located. Once they have isolated the bulk of the mass they instruct the anesthesiologist to waken the patient. The flow of sedative is cut-off and the patient is gently awakened. There is no alarm or sense of panic. The patient experiences no pain whatsoever.

Here’s where we talk about ‘Why?’

Brain tissue is extraordinarily delicate and responsible for so many critical life functions – everything from vision to memories and everything else in between. The goal of Senator Kennedy’s operation was to remove as much tumor as possible while sacrificing as little healthy brain tissue as possible. To accurately guide the neurosurgical team the patient performs a variety of wide-awake skills in the operating room: speech, movements, vision, cognition, etc. The surgeons know what activities correspond with various areas of brain anatomy. If a patient’s response falters the surgeons know they are very close to a critical region and tend to back-off. Remember, the patient experiences no discomfort whatsoever.

Once all or most of the tumor is removed the sedation is once again administered and the patient drifts back to sleep. The skull bone is replaced and the overlying scalp tissues are reattached. The Senator has an amazing mane of grey hair and it will grow back quickly as soon as chemo and radiation therapy is completed.

Pathologists will study the excised tissue and collaborate with the oncology team to develop a treatment plan that will offer Senator Kennedy the best prospects for survival while maintaining a satisfactory quality of life.

Oh, one last thing. Most of these fast-acting sedatives are highly amnestic. It is doubtful that Senator Kennedy will remember anything about his visit to the neurosurgical surgery suite. If he wants to learn more about the experience he may have to log on to WebMD!

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Posted by: Bill Lloyd MD at 5:21 pm


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