Eye On Vision

Resolve to See Better in 2009

2009-01-05T11:40:00.003-05:00

MESSAGE FROM DR. LLOYD: This is a modified version of a blog originally posted years ago, but the information remains accurate and timely.

'What can I do to see better or to protect my precious eyesight?'

My personal meta-analysis of our WebMD Vision & Eye Disorders message board has determined that to be the most commonly asked question.

There's no better time to make a resolution to keep your eyesight crisp and your eyes comfortable all year long.

Here's all you need to do:

Everybody: Have regular eye exams.

Smokers: Stop smoking!

Everybody: Watch your weight and your blood pressure

Diabetics: Control your blood glucose.

Everybody: Take a daily multivitamin loaded with antioxidants.

Athletes: Use protective eyewear made of durable polycarbonate.

Everybody: Wear sunglasses with 100% UVA/UVB protection.

Young males: Stay away from firecrackers.

Everybody: Know your family history for glaucoma and other eye disorders.

Travelers: Frequently apply artificial tears when in-flight.

Everybody: Wash your hands frequently.

By observing the above precautions you give yourself the best possible protection against the leading, treatable eye problems: refractive errors, glaucoma, cataract, age-related macular degeneration, eye trauma, pink eye (conjunctivitis), dry eyes, diabetic retinopathy, ischemic eye disease, and eyelid skin cancers.

WebMD wishes everybody a healthy and visually stimulating 2009!

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Shortest Days Approaching

2008-12-09T08:50:00.007-05:00

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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FDA Ponders Prescription for Luscious Lashes

2008-12-05T15:07:00.000-05:00

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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Can YOU See in 3-D?

2008-12-03T01:35:00.001-05:00

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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When Things Appear Clear but Different

2008-11-18T15:55:00.002-05:00

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.

Next Millennium Drug Delivery

2008-11-17T15:29:00.000-05:00

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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Permanently Pain-Free...Feel Good to You?

2008-11-11T16:31:00.006-05:00

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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How Does Squinting Improve Eyesight?

2008-11-04T11:43:00.002-05:00

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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Med School: What's in a Name?

2008-10-27T11:14:00.003-04:00

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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Don't Give Me the Flu

2008-10-19T12:55:00.001-04:00

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.

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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Consider Yourself a Gym Rat?

2008-10-13T12:01:00.010-04:00

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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Financial Jitters?

2008-10-09T16:20:00.003-04:00

It's hard to write about healthy vision when I'm distracted. All that I can see these days is red ink!

I'm getting queasy feelings.

Check this out. I just got done talking to my financial advisor about the current economic crisis. Most of the time this guy is a crackerjack, confidently recommending surefire investments that usually do well. Just as often he'll call to advise me when to make adjustments to my IRA. Simply stated, the fellow always had a quick answer.

Today he had no answers...not even predictions. I've never heard him equivocate before and this made me very concerned. 'Hey! If my financial advisor has run out of ideas what are the rest of us supposed to do?'

Are you having queasy feelings, too?

As of today the stock market has lost 35% of its value from its peak a year ago. Guess what? It's not as bad as you may think. During the 2001-2003 Internet bubble collapse stocks tanked 50%! Of course, the circumstances and the market dynamics are very different - tech stock speculators back then versus decimation of the national housing market today. There's no guarantee we will experience a similar rebound over the next 4 years, but I hope we do.

Fear can be misinterpreted as apathy. I haven't changed anything in my portfolio yet because I'm guessing that the future will be better than the present. Most of my stock investments involve blue chip companies that will still be around after the dust has settled. If I sell-off the stock I'll take a loss and have to pay a commission before I can reinvest the funds. Oh, reinvestment isn't free either. Then after everything improves I'll pay more commissions to get back into stocks. Ouch!

Some folks are totally cashing-out, buying insured CDs or US Treasury bonds. Nobody seems interested in the interest rates, they just want a safe haven. I hope they find it. A neighbor of mine has a big safe in his house and he has been hoarding cash over the past few months. Would you consider that wise planning?

I'd like to hear from others with their reactions to the national (er, global!) financial mess. Maybe with some smart advice I would become less distracted and feel a little less queasy.

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Photo credit: ©iStockphoto.com/LilliDay

One Eyedrop Worth Asking For

2008-10-07T16:16:00.003-04:00

Most folks with healthy eyes who undergo cataract surgery usually sail through the procedure. Within weeks the patient enjoys crisp, colorful vision that they haven't experienced in years.

However, some folks have a more rocky course. One big boulder along the road to full vision recovery is something called cystoid macular edema (CME). This is a leading cause of delayed vision recovery after cataract surgery and, for a minority of patients, permanent vision loss. It is very frustrating to the patient and surgeon because the cataract surgery and the intraocular lens implantation may have been flawless yet the patient still can't see well enough to drive safely.

The macula is that small region of the retina used for reading and precise focusing. How small, you ask? It's a circular area approximately one-third inch in diameter... roughly the diameter of the eraser at the end of a new pencil. Any changes to the macula can have profound visual changes: trauma, bleeding, inflammation, swelling (edema).

Here's what happens during CME: Leaky retinal capillaries in the vicinity of the macula lead to pockets of accumulated fluid that cause the macula to thicken - just like a recently sprained ankle. It can be quickly diagnosed with the doctor's ophthalmoscope and confirmed with a simple OCT scan performed in the clinic.

Lots of factors contribute to the development of CME after cataract surgery and many are preventable. Ophthalmologists know it is far better for the eye to prevent CME than have to treat CME.

New clinical research offers evidence that the daily application of nonsteroidal eyedrops for 3 days prior to cataract surgery significantly reduces the incidence of CME. Now, here's the good part. Nearly every cataract surgery patient will be taking those identical eyedrops after surgery anyway, so it won't cost any extra money. Simply begin taking the nonsteroidal eyedrops before the operation.

If you know someone anticipating cataract surgery be sure to pass along this valuable nugget: Ask the surgeon about using the post-op nonsteroidal eyedrops prior to surgery. Get a head start on CME; it could make all the difference in the world!

REFERENCE: American Journal of Ophthalmology, October 2008, pages: 554-560.

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SPOOKY: Do Ghosts Really Perform Surgery?

2008-10-01T23:13:00.002-04:00

Ever heard the phrase 'ghost surgery'? It can be a very scary topic.

Ghost surgery exists whenever an individual performing an operation is not the same person that the patient expected to be wielding the scapel.

In some busy practices the patient is led to believe (let's simply say 'underinformed') that their hotshot superstar surgeon will perform the procedure. Hotshots often charge more than what is covered by insurance and patients are willing to pay the difference in order to benefit from Dr. Hotshot's advanced skills and experience. Sadly, Dr. Nobody may actually operate on the unknowing (asleep) patient. This is a deeply unethical medical practice.

Ghost surgery can also arise in the training environment. Young surgeons in need of experience sometimes develop their techniques on unsuspecting patients who believed that the attending staff surgeon was in charge. This, too, is unethical. It does not involve reimbursement revenues but it corrodes the trust patients put in their doctors.

Now, let's be realistic. Residents have to learn how to perform surgery somewhere, right?!? A well-structured clinical residency program is the ideal environment for senior surgeons to train their successors. Standing side-by-side the staff and resident surgeons collaborate to get the best results for their patients. If portions of a case are too precarious or too unfamiliar to the young protegé the more experienced attending surgeon typically takes over. The patient is protected every step of the way.

It is the responsibility of the attending surgeon to approach the patient and ask this important question. If a patient declines to have a surgeon-in-training scrub-in the choice needs to be respected. Fortunately, this is a rare occurrence.

Here's a neat secret: If you are ever brought to the hospital in the middle of the night needing surgery, and they offer you two options: Surgery Chief Resident (cub) or Chief of Surgery (lion) go with the Chief Resident! As a general rule, that young doctor has recently performed an enormous volume of surgical procedures and knows the latest and greatest ways to fix you up. The Chief of Surgery spends a lot of time going to meetings and performs far less surgery.

So, how do most folks feel about a resident serving as primary surgeon with staff supervision? A recently published study collected patients' feelings on the subject with the use of an anonymous survey distributed to 106 preoperative patients needing cataract surgery. Here's what they found:

96% felt that they should always be asked (no ghost surgery)

83% claimed that they would agree to let the resident assist the attending surgeon perform the eye operation

55% felt that the standard pre-op consent form was adequate disclosure (who reads those anyway?!?)

49% claimed that they would allow the resident to be the primary surgeon

If you or a loved one is anticipating surgery make sure you clearly understand all options. Make sure that ghost surgery is not tolerated in your hospital. Specifically ask who will serve as primary surgeon and their level of proficiency. Do not abdicate that decision to anyone!

REFERENCE: Archives of Ophthalmology, September 2008, pages 1235-1239.

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Tiny Chip Accelerated Huge Advances in Eye Care

2008-09-24T19:43:00.000-04:00

Did you hear about last week's big anniversary? Maybe not, but most geeks were partying!

The very first working integrated circuit was introduced 50 years ago. That means the so-called Digital Age is now half a century old.

Integrated circuits (microchips) gradually replaced traditional vacuum tubes and discrete electrical components. This innovation reduced the size, reduced the weight and greatly imporoved the overall functionality of nearly everything electrical in our lives. Beyond a simple on/off switch, integrated circuits allowed devices with semiconductors to store data and display information to the user.

Yes, the personal computer was one important outgrowth of the digital revolution. Back in college we had to feed punch cards into huge (room sized) computers in order to develop simple computer programs. Ugh, how primitive! Today's laptops reliably store more data and process it much faster than any of the giant central computers.

If you walk around your house you will locate ICs in your TV, telephone, DVD player, Gameboy, home security system, as well as your electric toothbrush and digital alarm clock.

Eye specialists are especially appreciative for semiconductor technology. Most of the phenomenal imaging equipment in the eye clinic relies on ICs. Sophisticated tests can be quickly performed and instantly compared to previous exams. Many clinics are going 100% paperless thanks to electronic medical recordkeeping.

Laser therapy for retinal disorders would not exist without ICs, nor would LASIK. Enough said.

Heard about the miraculous 'artificial retina' microchip coming down the road? Yep, it's a tiny IC implanted into the eye!

Want more proof? When I began performing my earliest cataract operations we relied on gravity and suction to perform intraocular surgery. Need more fluid pressure? Simply raise the bag of irrigating solution! Today the eye surgeon benefits with sophisticated instrumentation that is precisely controlled by ICs. Nowadays the confident surgeon controls the equipment with delicate foot pedals or a voice-activated sensor. Integrated circuits can rightfully take ample credit for the tremendous improvement in surgical outcomes over the past generation.

The development of integrated circuits has truly revolutionized our world. In 1990 Jack Kilby of Texas Instruments received the Nobel Prize for his invention. According to the President of the Semiconductor Industry Association, "The integrated circuit has proved to be the single most important driver of increased productivity and economic growth in history."

And remember, this all happened in the past 50 years. 2058 is just around the corner!

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What Should You Expect After Eye Surgery?

2008-09-16T13:48:00.003-04:00

Many individuals are understandably anxious during the days leading up to an eye operation, especially if it is a first time thing. Fortunately, most folks sail through their procedure and are back home before they know it.

But for many that's just when the real anxiety sets in.

"My eye looks somewhat red. Is there a problem?"

"I'm not seeing as clearly as I had expected. Is there a problem?"

"My eye sure feels a bit scratchy. Is there a problem?"

Compared to past decades, surgeons today spend more time engaged in preoperative consultation and that's a good thing. Nobody should consent to undergo any kind of procedure until they fully understand the proposed benefits, the potential for complications, and the availability of effective alternatives.

Nowadays more often it's the postoperative counseling that gets short shrift.

(Etymological digression about the phrase 'short shrift': A shrift is a penance imposed by a priest in confession to forgive past sins, often when the confessor was near to death. In the 17th century, criminals were sent to the scaffold immediately after sentencing and only had time for a 'short shrift' before being hanged. Who knew?)

Many patients head home from surgery with inadequate guidance. There are several explanations for this oversight:

Busy surgeons are eager to move on to their next scheduled patient because O.R. time is extremely precious.

Many patients receive a preoperative sedative to relax them during surgery. That sedative often renders them incapable of remembering anything. We call this anterograde amnesia.

Many clinics bundle preoperative and postoperative counseling for the sake of administrative efficiency - only to leave the patient totally overwhelmed with instructions and a handful of handout materials.

And so, patients are prone to worry about anything that seems out-of-the-ordinary following an eye operation. Who can blame them?

Scratchy eye: Is it a temporary bout of postoperative dry eye or has a suture come loose?

Eye pain: Is it normal healing or an early warning sign for infection?

Bloodshot: Did this hemorrhage result from surgery or is something amiss?

Nobody wants surprises, especially after an eye operation. If you or a loved one is anticipating eye surgery make sure you clearly understand what to expect after the procedure. What are the most commonly encountered postoperative symptoms and how should they be managed? Inquire about what to do if a problem is suspected. In other words, when should the doctor be called?

Finally, and this is really important, make sure you have accurate phone numbers that will give you emergency access to your doctor during off-hours.

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Why Some Glaucoma Patients Are Miserable

2008-09-11T19:39:00.001-04:00

Glaucoma patients have a lot on their minds.

First, they are coping with the potential for irreversible vision loss.

Next, they often have to take pressure-lowering eyedrops several times a day. This can become a complicated routine, especially for older adults.

Of course, these folks have to find a way to pay for their medications.

Besides that, many glaucoma patients experience chronic eye discomfort. New research implicates a preservative in the eyedrops as the culprit.

Benzalkonium chloride (BAK) has been used for decades to keep eyedrop medications sterile. Most bottles of eyedrops are intended to be used for a month or more. These bottles are stored in pockets and purses, atop desks and bathroom sinks. They are opened and handled by humans several times a day and, guess what, humans are inadvertently unsanitary at times. BAK keeps the medication safe and germ-free.

Good protection, however, comes at a price.

Glaucoma researchers writing in the August 2008 issue of Journal of Glaucoma identify BAK as a leading contributor to ocular surface abnormalities. By ocular surface we mean the multilayered tear film that coats the eyeball: a water layer, a mucus layer, and an outer oily layer that prevents tear evaporation. If you have a unbalanced tear film your eyes will feel bad and look bad.

The doctors studied 109 adults taking anti-glaucoma eyedrops. Each patient completed an Ocular Surface Disease Index questionnaire and underwent evaluation by Schirmer test, corneal and conjunctival lissamine green staining, and tear break-up time. It turns out that 65% of subjects had tear film abnormalities and prescription eyedrops with BAK twice as often generated chronic eye discomfort.

The researchers concluded that a large proportion of patients with open-angle glaucoma or ocular hypertension had signs and/or symptoms of ocular surface disease in at least 1 eye. The coexistence of ocular surface disease and the use of BAK-containing medications may impact vision-related quality of life in this patient population.

Bottom line: If you take eyedrops for glaucoma and your eyes feel irritated or look irritated ask your doctor if your eyedrops contain BAK and if an alternative BAK-free eyedrop can be substituted.

REFERENCE: Journal of Glaucoma, August 2008, pages: 350-355

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LASIK: Visible Proof

2008-09-04T10:40:00.000-04:00

A recent visitor to our WebMD Vision & Eye Disorders message board asked a very interesting question:

4 years after uncomplicated LASIK can an examiner tell whether or not an eye has had previous LASIK?

That's a very interesting question and it immediately prompts me to think:

Why would you want to know?

First things first, since LASIK surgery includes creation of a superficial flap of corneal tissue the edges of the flap are usually visible for years afterwards. Sometimes the edges heal extremely well, making it nearly imperceptible, but a careful magnified examination using the slit lamp biomicroscope will expose the flap incision.

Besides the flap edges there are other visible clues to alert the examiner to the presence of earlier LASIK. Clumps of migrating surface cells and grey-white patches of scar tissue can accumulate underneath the flap. These features jump out right away.

Now, about my question. Who would want to know if somebody had undergone previous LASIK?

Many careers require excellent eyesight without refractive correction. It goes beyond aviators. Many law enforcement jobs, security jobs, and other occupations demand crystal clear vision. Folks eager to qualify for a dream job will do what they feel is necessary to get hired. Such enthusiasm is honorable but it can backfire. Perfect LASIK may still leave you needing spectacles for residual error. Moreover, refractive surgery may affect your near vision and force you to obtain (disqualifying) reading eyeglasses. Finally, some employers exclude candidates with a history of prior eye surgery.

Here's some good advice. Invest wisely and make sure you fully understand all of the hiring criteria before paying for expensive refractive surgery.

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Do Lazy-Eye Treatments Really Work?

2008-08-22T09:25:00.000-04:00

Photo Credit: Bill Lloyd

Amblyopia (lazy-eye) is the leading cause of vision loss affecting one eye. It develops in early childhood when the brain receives different visual images from the two eyes: one clearer, one blurrier. The brain accepts the clearer image and disregards input from the fellow eye.

Here's why many children develop lazy eye:

The refractive error between the two eyes may be significantly different

The eyes may be crooked

Something is blocking focused light rays from reaching the retina (like a juvenile cataract)

Click here to read a more detailed post about amblyopia.

True to its name, lazy eye appears to be, well, lazy! So long as the child is being treated (whether with patching or atropine eyedrops) vision recovery is steady and predictable. The problems come when the treatment stops. New research about lazy eye shows that most 10 year-olds previously treated for their amblyopia still have a residual vision deficit.

This national study followed 176 children with moderate amblyopia from the time of diagnosis until age 10. The average age at enrollment was 5 (even though their lazy eye had likely been present for years). As predicted, children whose treatment was initiated before age 5 fared much better than latecomers who enrolled after their fifth birthday. Young brains are more 'plastic', more responsive to amblyopia treatment. The earlier the lazy eye is treated the greater the effect of treatment and the more time is available to reverse the problem. Sometime around age 7 years the brain 'hardens' and becomes less responsive to lazy eye treatment.

Here's what they found when they analyzed the entire group at age 10:

Most of the vision improvement from earlier amblyopia treatment was maintained

Some residual lazy eye persists in most treated children

Patching and atropine eyedrops achieve similar benefits

Earlier treatment results in better the long-term visual outcome

Most children received no treatment beyond age 9

Most of these children continued to wear prescribed eyeglasses. Remember, parents, every case is different and all children respond differently to lazy eye treatment. The key take home message is that early diagnosis and treatment of amblyopia offer the best opportunity to recover lost eyesight. If treatment fails go back and try again because time is on your side.

REFERENCE: Archives of Ophthalmology, August 2008, pages 1039-1044.

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Technorati Tags: amblyopia, lazy eye, children, vision

Phelps' Win: Faster than a Blink!

2008-08-18T16:21:00.002-04:00

Photo Credit: Sports Illustrated / Getty Images

Did you catch Michael Phelps extraordinary win in the Men's 100m Butterfly finals at the Beijing Olympics? Were you able to watch it live? Did you actually see him win?

I doubt it. Nobody saw him win. Only the cameras saw Michael Phelps win!

Phelps took the gold by outreaching Serb swimmer Milorad Cavic and winning by one-hundredth of a second.

Gold: 50.58 seconds
Silver: 50.59 seconds

According to Swimming USA experts, one-hundredth of a second is the smallest margin that the touch-sensitive pool panels can record. Thankfully nobody had to rely on a hand-held stopwatch. More thankfully, nobody had to rely on a human's eyesight to judge the finish.

That's because human vision cannot discern what happens in 10 milliseconds (the same as one-hundredth of a second).

The eye blinks in 50 milliseconds and we are completely unaware that it has happened. An auto airbag fully deploys in 50 milliseconds and passengers never see it happening. Both of these events took five times as long as Phelps' winning margin.

It was exciting to watch the ultra-slow motion replay of Phelps' victory. Funny, the more often I watched it his winning margin appeared to increase - to at least 20 milliseconds!

A great win for Phelps, a great victory for Team USA, and a great achievement for today's digital technology. Everybody wins, except poor Milorad!

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Technorati Tags: Michael Phelps, Beijing Olympics, butterfly, swimming, vision

Unreal Olympic Moments

2008-08-14T11:53:00.003-04:00

Photo Credit: Ligadier Truffaut

How much time have you spent in front of the TV this past week watching the Olympics?

For me it has been a mesmerizing experience:

Fabulous opening night pyrotechnic effects (...except for the fake giant footprints China digitally created on screen!)

Inspiring singing voices (...except for the little girl whose voice was dubbed!)

I wonder how many other phony parts were incorporated into the opening ceremonies that have not been exposed yet?

Of course show business always involves a certain amount of deceit. And show business doesn't get any bigger than the Olympics. For example, many movies rely heavily on computer-generated effects. Maybe so, but we enter the theater with the full understanding that we are watching artificially manipulated imagery, right?

We expect every moment of the Olympics to be real...except for the color of Bob Costas' hair.

When USA hosts a spectacle we don't feature bogus illusions, we give the people what they came for: costume malfunctions!

Beijing organizers were totally unapologetic. They claim that the end results (wild applause) justified the use of trickery. Every parent of a 9 year-old can refute that argument..."So, you're saying that the ends justifies the means?"

They just don't get it.

Maybe they apply the same misplaced logic to their economy, to their environment, to their military: Looks great, but much of it is faked!

Photo Credit: Ligadier Truffaut

Hmmm...do you think they really used 2008 synchronized drummers in the beginning? Replay it slowly. Many of the drummers look alike. I'm becoming suspicious of a cut-and-paste of Olympic proportions!

Please tell me if you think I'm wrong. That's something very real that we can do everyday here in America!

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TRUE! More Playtime...Less Myopia

2008-08-13T12:13:00.001-04:00

Photo Credit: Eric Lewis

Yes, what you've read is true! It now appears that the more time children spend outdoors the less likely they will become nearsighted.

As America's obesity epidemic continues its expansion, more and more children are growing up chubby. This news creates another powerful reason to get your kids outside and burn some of those excess calories.

A newly published report from the University of Sydney, Australia, examined two large groups of children: 6 year-olds and 12 year-olds. That's important because myopia (nearsightedness) usually has its onset and greatest progression during school years.

All children received precise refractions after their eyes were fully dilated. This cycloplegic refraction permitted the examiner to accurately measure every speck of refractive error in these children.

Detailed questionnaires were then given to the parents. This survey wanted to know how much time the child spent in school, at play outdoors, reading, computing, video gaming, and other visual activities. Now, since it was Australia the survey also asked about indigenous activities such as bush walking! Statisticians then went back and correlated data from the questionnaires to individual refractions.

Here's what they found, mate!

12 year-old students who logged the greatest amount of time outdoors had the least amount of myopia. Bookworms who rarely bush walked were far more likely to become nearsighted by age 12.

Vision researchers are still in the dark trying to identify explanation for these results. We've known that excessive accommodation in youth contributes to myopia and long-term use of atropine eyedrops paralyzes accommodation and halts the myopic shift. Of course, not much accommodation takes place outdoors in the sun. Bright sunlight shrinks the pupil leading to a greater depth of focusing and less image blur. Additionally, we know that light-stimulated retinas release the powerful neurotransmitter dopamine, and dopamine is a known inhibitor of eyeball growth. Eyeballs physically become myopic when they elongate, so anything that halts elongation of the eye, like elevated dopamine, could theoretically prevent myopia from developing.

Slather them with sunscreen then get your children outside today, and keep them out there until dinnertime. What a bright idea!

SOURCE: Ophthalmology, August 2008, pages 1279-1285.

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Technorati Tags: myopia, childrens vision, play

Something Can Be Done!

2008-08-07T08:00:00.000-04:00

Photo Credit: Bill Lloyd, MD

Have you felt it?

Recently there has been a run of pessimism on our WebMD Vision & Eye Disorders message board. An unusually large percentage of visitors are suffering, worried, frustrated, or all of the above. A common thread running through these messages is exhaustion...everything has been tried and there appears to be little more for their doctors to offer.

"Isn't there anything else that can be done?"

This is a critical point in the patient care experience and it can define when doctors actually become healers.

Here's what I know: There is always something else that can be done.

Trying again - Some treatments don't work the first time. Laser treatment for diabetic retinopathy often has to be repeated. The trick here is to be patient and give your treatment sufficient time to work. Don't hesitate to ask the doctor, "Would it help to repeat this treatment?"

Alternatives - When Doctor A informs you she has nothing else to offer, perhaps Doctor B does! It could be clinical expertise or technology. Some physicians are reluctant to refer patients elsewhere for fear of losing them permanently. Keep probing for answers. Don't hesitate to ask the doctor, "Can you recommend someone else who has experience dealing with my problem?"

Innovative options - If conventional treatments are unsuccessful it may be time to think outside the box. Are any investigative clinical research studies being conducted to explore your condition? Off-label use of FDA-approved drugs frequently leads to drug breakthroughs. Avastin, Topamax, and even the previously-banned Thalidomide found new ways to relieve "incurable" diagnoses. Don't hesitate to ask the doctor, "Who is doing the most research about this condition?"

Never stop caring - Even if the disease cannot be reversed, even if the eye goes blind, even if the blind eyeball shrinks and disappears, the need for caring never stops. Maybe vision cannot be restored but the patient can still be supported. The fellow eye will require protection and close observation. There will be emotional/behavioral adjustment issues related to the permanent loss of vision. Eye discomfort and cosmetic appearance can always be optimized. Opportunities to care are limited only by the physician's compassion and creativity.

So, remember this. The next time you hear some doctor declare, "I'm so sorry, but there's really nothing that can be done," don't become angry. Find comfort in the knowledge that you have identified that physician's limits. Time to find a new physician.

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Technorati Tags: vision, eye health

Moisturize with Mother Nature!

2008-07-29T12:30:00.002-04:00

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