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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, July 29, 2008

Moisturize with Mother Nature!

Photo Credit: Joe Loong

Chemical engineering researchers at McMaster University have shown that a natural substance found in our bodies can be used as a natural moisturizing agent in contact lenses. This is a step up from the current wave of self-moisturizing contact lenses that use synthetic materials as a wetting agent to prevent eye dryness and increase wearer comfort.

It is estimated that more than half of all people who stop wearing contact lenses do so because of discomfort caused by dryness, which progressively worsens as the day wears on. New research from McMaster, recently published in the journal Biomaterials, showed that hyaluronic acid can be entrapped in existing contact lens material without affecting its optical properties.

More good news! It was also found that using hyaluronic acid considerably reduces the build up of proteins which can cloudy contact lens material, the cause of up to 30 per cent of all after-care visits by contact lens wearers to optometrists.

Hyaluronic acid is a natural polymer that acts to reduce friction. Our bodies continuously synthesize the slimy stuff. An average person weighing 70 kg has about 15 grams of hyaluronic acid in their body, one third of which is turned over daily. The body uses hyaluronic acid to repair skin, provide resiliency in cartilage, and contribute to the growth and movement of cells, among other things. Hyaluronic acid is the major non-water component to the clear vitreous that fills the eyeball.

Purified nonhuman hyaluronic acid used by the medical profession to eliminate wrinkles, to treat patients with dry eyes, and it is injected inside the eye during cataract surgery and other eye procedures.

Although manufacturers have not yet produced contact lenses with hyaluronic acid, the researchers remain hopeful. “We’ve shown that the process works,” said Heather Sheardown, professor of chemical engineering at McMaster and a member of the McMaster School of Biomedical Engineering, who was involved in the research. “We’re optimistic that a manufacturer will see the benefits of using this naturally based technology to provide contact lens wearers with greater comfort and convenience.”

SOURCE: Review of Ophthalmology, online version, 7/28/2008

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Technorati Tags: contact lens, hyaluronic acid, vision

Posted by: Bill Lloyd MD at 12:30 pm

Thursday, July 24, 2008

Tips for College Frosh Parents

The last few weeks before an older child enters college are always exciting, always busy, and usually very expensive! That first college tuition statement is always a shock

Having sent three to college I wanted to share some ideas regarding coed health.

Make sure your student receives all of the appropriate immunizations, especially the Meningococcus vaccine to protect from bacterial meningitis (a preventable campus killer).

Check that your child’s health insurance coverage does not lapse. Call your health plan to make sure your child is eligible even if they are far away. Out-of-network coverage can be very expensive. Consider a supplemental policy to cover unpaid portions of your primary health plan. Otherwise, enroll your child in the college health insurance plan. Listen to me, an overnight hospitalization with appendicitis can easily cost $15,000.

Photo Credit: Marco Antonio Torres

Book an appointment for your student to visit the eye doctor. Have any spectacle prescriptions updated. Make a bulk purchase of contact lenses and supplies. Ask for duplicate written copies of all prescriptions for use in case of loss or breakage. Things happen, right?!?

Remember, goods and services are always more costly when purchased far from home. Tackling these chores now will spare you anxiety, time and money once school starts.

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Technorati Tags: college students, meningitis, health and wellness

Posted by: Bill Lloyd MD at 6:41 am

Tuesday, July 22, 2008

Nothing to Sneeze At!

AHHH-CHOO!!!

Although this specific WebMD blog is devoted to the marvels of vision this post marks the second time I find myself talking about sneezing!

A while back I wrote about photic sneezing, a harmless natural reflex that results when a bright light is shined into someone’s eye. It happens frequently in the clinic so I always keep a few extra boxes of tissue nearby!

Now we learn about a different kind of sneezing phenomenon – and this one carries a warning label! It’s called ‘injection sneezing’.

Here’s what happens: when people are awake for surgery involving the eye or orbit they often receive an injection of local anesthetic to numb the tissues surrounding the eye (periocular anesthesia). Most of the time a small dose of intravenous sedation is administered to relax the patient, but the patient is technically still awake (yet carefree!)

Surgeons from Albany Medical Center noticed a trend. Sedated patients experienced a vigorous sneeze at the time the local anesthetic was injected. You can imagine the potential for disaster as somebody launches a forceful sneeze while a very sharp needle is near the eyeball. The eye could be perforated, delicate anatomy could be traumatized, bleeding could ensue, and infection could always make any complication worse.

So, how real is the risk of unwanted sneezing? These doctors reviewed over 700 cases involving periocular anesthesia. When the patient received IV sedation, sneezing occurred 5% of the time – once in every 20 cases. Interestingly, when no IV sedation was used no sneezing was observed whatsoever.

How can this information be helpful to you? If you are scheduled for eye surgery that involves IV sedation, make sure you and your doctor agree on the need for periocular anesthesia. If the surgeon deems that periocular anesthesia is necessary there are extra precautions that can be taken to protect vulnerable patients.

REFERENCE: American Journal of Ophthalmology, July 2008, pp 31-35.

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Technorati Tags: photic sneezing, injection sneezing, periocular anesthesia, eye surgery

Posted by: Bill Lloyd MD at 10:45 am

Friday, July 18, 2008

Too Much Surgery?

Sometimes what starts out as one eye operation turns out to be four…sometimes six.

With all respect to my dermatology colleagues, performing an eye operation is not like having a wart frozen. “There, that’s done. You’re cured!”

Eye surgeons frequently counsel their preoperative patients that it’s possible that more surgery may be needed down the road. Here are some of the more common reasons for that precaution:

  • The original surgery could not be not completed. This happens during cataract surgery if a chunk of lens material falls away into the back of the eye. The judicious action is to schedule a second procedure to retrieve any residual lens fragments.
  • Something new was discovered. During performance of the planned eye operation the surgeon discovers a new problem that was not recognized beforehand. If the cornea is cloudy or if the eye is full of blood it may not be possible to fully assess all of the problems prior to surgery.
  • The first operation was so successful that new symptoms emerge. After years of poor vision an eye can drift. Fixing the vision problem may leave the patient with double vision since the previously poorly-seeing is slightly misaligned. Adjustable eye muscle surgery may help eliminate that situation.
  • Complications can occur. A small percentage of patients develop problems related to surgery (infection, bleeding, elevated pressure, retinal detachment, dislocated lens implants, etc.). Most of the time the problem can be fixed with a second procedure.

The surgeon must balance the patient’s need for another trip to the O.R. with the knowledge that too many operations may be unhealthy for the eye. Delicate limbal stem cells on the surface of the eye are essential to a healthy ocular surface and these stem cells are often damaged with the ‘trauma’ of entering the eye. Another cell population, the corneal endothelia, are also compromised every time surgical instruments enter the eye.

Darned if you do, darned if you don’t? Not necessarily!

Common sense must prevail. If the patient is likely to benefit from another operation then the procedure will likely be scheduled. Having said that, after all of the fixable eye problems are ‘fixed’ there may still be the need for one more procedure like a corneal transplant or limbal stem cell autograft.

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Technorati Tags: eye surgery, vision

Posted by: Bill Lloyd MD at 8:24 am

Wednesday, July 16, 2008

Congress Reverses Medicare Cuts

As predicted in a recent WebMD blog, Congress has voted to reverse a scheduled 10.6% cut in Medicare reimbursements. Moreover, instead of another planned cut of 5% in January 2009 there will actually be a 1.1% increase in Medicare payments. Click here to learn how Congress got itself into this mess in the first place.

So everybody can take a deep breath and relax for a little while. Now some doctors can get back to work.

Yes, I said back to work.

Due to the severe nature of the projected Medicare cuts (as well as its trickle-down effect on all other government and private health plans) some doctors closed their offices except for genuine emergencies. Dr. David Richardson is an Los Angeles ophthalmologist who took that extreme measure. No routine appointments – emergencies only. Was it really that extreme?

Simple business practices demand that revenues (reimbursements for services) must exceed the costs required to operate that practice. Did you know that over half of what doctors collect immediately goes towards paying overhead? The key word is collect. If you ever examined one of those computer-generated “Explanation of Benefits” from your health insurer (an oxymoron, they actually explain very little) you’ll discover that there is an enormous gap between what the doctor legally bills and what insurance agrees to pay. It’s not unusual for a doctor to perform a 45 minute procedure, bill $1100, and collect $307! Remember, half of that disappears with overhead, and nobody has paid any taxes yet!

So let me ask you, would you be upset if your physician restricted services, curtailed clinic hours, or barred Medicare beneficiaries all in the name of keeping the practice solvent? Think about it, then let’s hear from you!

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Technorati Tags: Medicare, physician reimbursement, Congress, health and wellness

Posted by: Bill Lloyd MD at 8:54 am

Wednesday, July 9, 2008

Heart Attack…Eye Attack?

There are lots of news stories this week regarding the long-term benefits of maintaining normal blood cholesterol levels (HDL, LDL, triglycerides). The lifetime risk of stroke and heart attack may be cut by 36% in the United States over the next 30 years if everyone with elevated lipids is diagnosed and treated. Some pediatricians now advocate prescribing statins for susceptible children.

Most of you know the sequence: a fatty diet plus hereditary tendencies combine to elevate the blood cholesterol. In response to all this circulating cholesterol, the arteries form atherosclerotic plaques that shrink the openings of the arteries. Smaller vessels reduce the amount of fresh blood and fresh oxygen that can be delivered to the tissues. If atherosclerosis compromises the coronary arteries the poorly oxygenated heart muscle will starve (myocardial infarction). Coronary artery occlusion can be reversed with angioplasty (stent placement), laser treatment, and surgical grafting of new vessels that bypass the clogged arteries (coronary artery bypass graft – CABG).

Can atherosclerosis occur inside the eye? Do people ever develop a Retinal Infarct?

Retinal artery occlusion is a true emergency, but it is different than a myocardial infarct. Did you know that there are no true arteries inside the eye – only arterioles and capillaries. Atherosclerosis and cholesterol plaque formation does not occur inside the walls of these tiny vessels.

Having said that, retinal artery occlusion is frequently caused by a dislodged chunk of mineralized cholesterol from the large internal carotid artery in the neck. That chunk of cholesterol becomes an embolus just like a cork flowing downstream. Eventually it gets stuck when the dimensions of the embolus exceeds the opening of the downstream vessel. The results are immediate and catastrophic: sudden, painless loss of vision. Most of the time the vision loss caused by an embolic retinal artery occlusion is permanent and irreversible.

Remember, even if your family history for heart disease is pristine and you carry no risk factors for coronary atherosclerosis, you still need to pay attention to your cholesterol numbers to protect vital structures (like your eyes) from sudden vascular occlusion secondary to atherosclerosis arising elsewhere in your body.

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Technorati Tags: vision, cholesterol, atherosclerosis

Posted by: Bill Lloyd MD at 1:08 pm

Tuesday, July 8, 2008

16% Pay Cut: Would You Quit Your Job?

You may not be aware of this, but Congress is wrestling with some important budgetary issues that will affect nearly every family in America.

Years ago, in order to curb the rapid expansion of health care costs, Congress wrote a law that instituted automatic semi-annual cuts to physician reimbursements. This approach allowed politicians to revisit the Medicare mess less frequently while escaping lobbyists and angry doctors. Well, the strategy backfired and all parties agreed that a better approach was needed to achieve comprehensive health financing reform.

Nevertheless, the law remains on the books, so every year Congress votes to rescind the programmed cuts. According to their formula, a 10.6% cut in Medicare reimbursements was due to take effect on July 1 with an additional 5% for January 2009. That represents a 15.6% pay cut for doctors treating Medicare beneficiaries. Would you be willing to keep your job if your employer announced a 15.6% pay cut? Many would throw up their hands and declare, ‘I’m outta here!’

What about pediatricians and other physicians who do not see Medicare patients? Bad news – no one is immune. The Medicare reimbursement tables are the standard by which most government and private health plans base their fees. It is very likely that your doctors are holding their breath waiting to learn if they are about to withstand another financial hit. Doctors who refuse to see Medicare patients but welcome other insured patients are still penalized.

In a particularly vitriolic exchange, Democrats and Republicans blamed each other for what Dr. Nancy H. Nielsen, president of the American Medical Association, said has put the country “at the brink of a Medicare meltdown.”

“Seniors need continued access to the doctors they trust. It’s urgent that Congress make that happen,” the AMA said in ads taken out in Capitol Hill newspapers read by members of Congress and their aides.

Typically there is a last-minute Congressional reprieve from the Medicare cuts but this has not happened in 2008. Politicians and government bureaucrats are working feverishly to fix the situation but the clock is ticking. A vote to eliminate the cuts last week failed by just one vote in the Senate. As a temporary fix the Bush administration announced that Medicare will postpone the planned reduced reimbursements for 10 days by freezing all Medicare claims.

You might want to let your Representative or Senator know how you feel about this dilemma. Remember, your doctor is not asking for a pay raise. Like you, they simply want to hold on to what they earn.

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Technorati Tags: Medicare, doctor reimbursements, Congress

Posted by: Bill Lloyd MD at 9:05 am

Tuesday, July 1, 2008

Pocket Change: Barrier to Better Care

Last month this WebMD blog examined important reasons why some folks have problems taking all of their medications – the precise terminology is patient compliance. There are lots of reasons that contribute to poor compliance but the simplest one to appreciate is the fact that the patient never filled the prescription in the first place!

Now, at first glance, that doesn’t seem to make any sense at all: go to all the trouble to make an appointment, sit through the complete eye exam, listen to the doctor’s counseling, and then simply go home without any treatment whatsoever. What’s up with that?

What could possible deter an intelligent adult from getting an eyedrop prescription filled? What if the prescription cost $132? True, many might forego the prescription. What about $2 or even $1? Believe it or not, it happens every day.

A new study in the journal Medical Care claims that modest copayments significantly reduce drug usage. Pharmacologic researchers from the Oregon Health & Science University analyzed blinded data from a huge number of Oregon Medicaid records and discovered that enforcing a new $2 prescription copay rule led to an immediate 17% drop in prescription drug usage. Previously, Medicaid beneficiaries were not required to make copayments for prescription drugs. After the rule went into effect some folks simply refused to pay the $2 copay and went home empty-handed.

This study is not about poverty or under-served communities – its findings apply to everyone. The researchers used a Medicaid database because all of the required information was readily available from one electronic source. Trying to complete the same study involving the private insurance sector would be nearly impossible to accomplish.

Interestingly, copay refusal was not uniform. Diabetics and folks with cardiovascular diseases paid the money and continued their medications, whereas compliance rates for people with respiratory problems and depression decreased the most. Eyedrop prescriptions were somewhere in-between.

Maybe you’re mumbling to yourself, “Those cheapskates deserve to get sicker; they only have themselves to blame!” Whoa, not so fast! Anytime an unfilled prescription sits unused on the shelf it’s bad for everybody. Let’s say those who refuse to pay the $2 for each of their medications actually do get sicker and land in the hospital. Who will end up paying the bill? Taxpayers and those paying health insurance premiums will inevitably shoulder that debt. This problem cuts through all economic strata.

According to the research organizers, the few previous studies of this issue have also found comparable reductions in medication use in response to cost-sharing measures. This suggests that a more thoughtful approach to crafting cost-sharing policies should be considered. The authors suggest, for example, health plans should eliminate copays for drugs with strong evidence of effectiveness. In other words, don’t give folks an excuse not to take their medicine.

Until a national health care program is developed, doctors, patients and families need to make sure that everybody who is prescribed medication has access to their medicines and uses them as prescribed. Over the short term or over the long term, skipping medical therapy generates no savings whatsoever. It is a false economy.

REFERENCE: Medical Care, June 2008, Vol 46; pages 565-572.

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Technorati Tags: patient compliance, copay, drugs, medicine, health and wellness

Posted by: Bill Lloyd MD at 10:05 am

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