I have been seeing an increasing number of folks coming in for an opinion about their pterygium.  Most don’t know that is the name of the fleshy-looking growth on the nasal side of the cornea.  It has a triangular shape which looks somewhat like a wing, therefore the name “pterygium” which from the Greek means “wing.”  The pterygium may first appear as a reddish area on the nasal side of  the dark central part of the eye (the iris provides the color and the cornea is the clear window over it) only to grow onto the cornea as a fleshy membrane.  If left untreated, it has the potential to grow across the center of the cornea and result in a severe loss of vision.  It seems that the growth and development of pterrygia are related to sunlight so if you have noticed a small pterygium, get some good quality sunglasses. 

 There is no reason to treat small pterygia (as most don’t become large pterygia) unless they are irritating and/or growing.  I don’t often see middle aged people with pterygium problems, usually it becomes symptomatic  in people in their 20’s and 30’s.  I have found that the pterygium become stationary later in life.  Quite frequently patients will ask me to remove a pterygium which they have had for many years while I’m operating their cataracts; this is very possible.  Many people ask to have the pterygium removed for cosmetic reasons, ie, they are tired of answering the question: “what is that growing on your eye?”  But if the pterygium is growing, it is time to act and the only action is surgical removal.

The removal of a pterygium is low risk as the entire procedure is conducted on the outside of the eye.  The main risk is that it will recur after removal.  When I began doing this surgery early in my career, the recurrence rate was as high as twenty-five percent.  Back then we used low dose radiation applications to the eye to prevent recurrence.  This approach was inconvenient and didn’t do much good.  The next advance was the use of conjunctival grafts, that is, after the pterygium was removed we took a piece of the white filmy cover of the eye (conjunctiva) from under the eyelid and moved it to the surgical site and sewed it into place.  This helped reduce the recurrence rate but it made the surgery long and tedious.  At the same time we began using a drug called Mitomycin which was developed in the 1950’s for chemotherapy.  The Mitomycin was applied to the surgical area with sponges for several minutes to inhibit new scar formation and reduce the chances of regrowth.

All of this has evolved to the state of the art which is the use of an amniotic membrane  graft http://www.osref.org/medical-education-materials.aspx made of human placenta (only the inner basement membrane which is very thin) which is glued into place with fibrin glue http://www.baxter.ca/htdocs/en/doctors/biosurgery/products_tisseel.html (a human byproduct).  The placenta is first lab tested for contaminants then frozen and shipped to us.  When placed on the eye it provides stemcells which reduce inflammation and a barrier to recurrence.  It is readily absorbed onto the surface of the eye.  This approach coupled with Mitomycin has made the surgery reasonably fast and effective in terms of reduction of the recurrence rate.  Postoperative course consists of one night with a patch then several weeks of eyedrops; vision is good immediately and folks can resume their usual activities in a day or so.

This technique has its greatest benefit in patients who have had prior pterygium surgery with a poor outcome, that is, a recurrence.  If a graft with fibrin glue and Mitomycin is not done in these people, a further recurrence is a good probability. 

While this technique is not fullproof, it is currently the most effective treatment for pterygium.

Now that you have a visually significant cataract, that is, a cataract that is interfering with activities that you enjoy doing or those that you must do, the choice is no longer “should you do the surgery,” rather “how should the surgery be done.”  Needless to say, this decision must be made during a consultation with an ophthalmologist with whom you feel  comfortable.  Keep in mind that this is the last and best opportunity to not only remove your cataract but to correct other problems such as nearsightedness, farsightedness presbyopia and astigmatism.

To help with the discussion, the lens options fall into several classes; MONOFOCAL LENSES will deliver good vision at a single point in space, ie, distance or near.  A modern variation on this lens is the ASPHERIC LENS which has a curvature which neutralizes the curvature of the cornea and thus reduces glare and other types of distortion.  A TORIC LENS will correct astigmatism at the same time that it corrects nearsightedness or farsightedness and it has recently been manufactured in an aspheric form.  Then there are the MULTIFOCAL LENSES which are in many instances, aspheric as well.  These lenses correct for distance and near vision.  There is the Restor lens from Alcon Labs, the ReZoom lens and more recently the Tecnis lens from AMO.  In addition, the Crystalens from Bausch and Lomb which is somewhat different from the other lenses but ultimately yields a similar outcome.

The issue is that there are numerous lenses to place in the eye at the time of surgery. The lens must be matched to the patient’s visual needs, not the other way around; one lens does not fit all.  On the one hand, an 80 year old with macular degeneration and cataracts who does not mind wearing reading glasses would fair best with a lens that provides only distance vision and perhaps it should be an ASPHERIC LENS which minimizes glare and maximizes distant vision.  The opposite situation might occur in a 50 year old who needs distance vision, computer vision and reading vision and would be willing to wear reading glasses occassionally.  The latter case would call for a MULTIFOCAL LENS of which there are several. 

It must be said that every style of lens has different advantages and disadvantages and these must be reconciled with the patient; that is my job.  I must find out what you expect and want from the procedure.  What are the tasks that you want to do without glasses and which are you willing to occassionally put the glasses on in order to perform. 

Remember that cataracts come with having birthdays and perhaps this year’s present might be good vision and possibly no glasses to achieve that end.

Firstly, let us not refer to the condition as “dry eyes” rather “tear film deficiency” or “dysfunctional tear syndrome.”  The change in terminology reflects the updated understanding that the problem involves the entire lacrimal functioning unit as a whole and emphasizes tear film quality rather than tear volume.  In the past, the dry eye has been treated with the application of artificial tear alone to replace the volume, now the condition is recognized as an inflammatory disease and treatment is directed at the inflammatory component.

Tear film deficiency is extremely common with the incidence anywhere from 4% to 15% of the population over the age of 45 years and it is more prevalent in woman. 

 What causes this tear problem?  The lacrimal functional unit consists of the lacrimal gland (tear gland), the surface of the eye itself and the nerve connections between the two which passes through the brain.  When the cornea is not happy with the quality of tears, it sends a message to the brain which tells the lacrimal gland to get busy.  The lacrimal gland produces the tears which contain growth factors and other proteins.  In addition, the surface of the eye contributes lipids which reduce evaporation and mucins which enhance the spread of the tears on the eye.  The currently available studies indicate that the symptoms are related to inflammation of the ocular surface and lacrimal gland which disrupts their function.

There are numerous conditions which influence the development and worsening of the dry eye such as LASIK surgery, glaucoma medications, inflammatory diseases such as rheumatoid arthritis and other systemic diseases such as diabetes and Parkinson’s Disease.  Antidepressants, diuretics, hormones and antihistamines among other drugs are implicated in worsening the condition.

Treatment is determined by the level of severity of the symptoms.  For those with mild, intermitent problems due to changes in the environment, the approach is to use over the counter artificial tear substitutes.  In general, I find that you get what you pay for when it comes to these products, that is, the inexpensive generic drops do not work.  Products such as Optive, Systane, Hypotears are most effective.  When the symptoms worsen where your activities are impacted then more aggressive treatment is indicated.  Firstly, you might consider taking omega-3 fatty acids for their anti-inflammatory effect.  If there is eyelid inflammation, you might require antibiotic eye drops.  Sometimes, in the short term, cortisone eyedrops for a limited period might break the cycle.  Eyedrops such as Restasis are effective in reducing the  inflammation of the lacrimal gland and ocular surface.  Silicone plugs (punctum plugs) placed in the tear drainage canal will allow the tears to remain on the eye for a longer time.  There are drugs which stimulate the lacrimal gland to produce more tears (secretogogues) which are sometimes helpful. 

If we think about tear film deficiency as an inflammatory disease we will be much more effective in treating the condition than in years past when we looked at it solely as a lack of tear volume.

If you would like to review your dry eye issues with me just give a call and I will be happy to give you my best opinion.

There was a time in this country when the vegetables produced on farms had nutritional value and indeed they still do on small farms.  However, most of the vegetables we now eat are produced by farming conglomerates bent on extracting the most profit that they can from every acre of land.  The land is replanted without much rest and the crop is picked long before it ripens.  As a result, there  is little nutritional value in the fruits and vegetables we eat.  I think if we were to follow the minimum daily requirement as posted by government, we would be eating all day just to keep up.

For many years the American Medical Association was not in favor of nutritional supplementation but in 2002 they came around and in essence are agreeing with the notion that the nutritional value of food has declined and supplements may play a role in preventing cancer, heart disease, depression, and macular degeneration. 

Omega-3 fatty acids are emerging as an important supplement in the prevention of numerous eye related conditions.  Studies have shown that there is almost a 70% reduction in dry eye syndrome in women who consume five to six servings of tuna per week.  Tuna contains large quantities of omega-3.  Also, if you take in large amounts of omega-3, it tends to nutrilize the inflammatory effect of omega-6.  I would (although not studied) add flaxseed as a source of the omega-3. 

Cataract formation may be altered by the intake of lutein and zeaxanthin as demonstrated in the Carotenoids in Age-Related Eye Disease Study (AREDS).  As light passes through the lens of the eye for a lifetime, it stands to reason that the protein in the lens would be damaged (thus forming cataracts) by free radicals.  Carotenoids are strong antioxidants which nutrilize the free radicals.

Age related macular degeneration (ARMD) is a vision limiting condition which aflicts seniors.  The incidence will probably rise to near epidemic proportions as the population ages.  The AREDS demonstrated that folks taking lutein and zeaxanthin have a 35% to 55% reduction in the risk of both atrophic and neovascular ARMD.  The same study identified that omega-3 fatty acids will decrease the risk of the progression of ARMD.

There are numerous supplements on the market and you should consult your physician prior to taking any of them.  The AREDS study employed Ocuvite marketed by Bausch and Lomb so that is the standard.  It comes with and without zinc.  It does not contain omega-3 fatty acids, in which case that would be taken along with Ocuvite. 

There is little down-side risk to taking nutritional supplements.  If you get started taking them early in life you may reap the rewards later.  We all want to live well as long as we can and supplements may be one of the answers.