This may seem like an absurd title but when it comes to understanding how the various technologies can improve and alter your appearance, there appears to be a widespread lack of knowledge among my patients here in Miami. I’m referring to the modalities such as Botox, fillers like Juvederm, lasers for skin resurfacing and facelifts.
The key to understanding is determining whether the wrinkles are fixed or dynamic. Botox will improve dynamic wrinkles, that is, wrinkles that arise from facial expression. When we smile the lines around the eyes suddenly appear or the frown brings out the lines in the brow. These are dynamic wrinkles and are treatable with Botox. In general, the region of the face that can be managed is from the nose up to the hairline.
The fixed folds in the facial skin are the smile lines that radiate down from the nose area to the lips. The lines that start at the outer edge of the mouth and angle down to the jaw are fixed. This type of facial dynamic is treatable with fillers. The deeper and longer the fold the more filler is required to give a nice contour.
Laser skin resurfacing is usually a full face treatment designed to reduce or eliminate wrinkles where the collagen of the facial skin has degraded and the overlying surface has lost its vitality. The laser leads to collagen rejuvenation and secondary smooting of the surface. Sun damaged skin is readily improved with this technology.
Lastly, facelift surgery is an operating room procedure whch can lead to major changes in the appearance but requires a substantial commitment of time and money as recuperation takes weeks and fees are often prohibitive.
When properly applied, Botox, Juvederm and laser skin resurfacing can be combined in a sequential manner with minimum down-time and with dramatic results. I will be happy to discuss these options with interested folks.
Folks with advanced macular degeneration loose their central vision and retain the peripheral vision. When they look at your face at close range, the eyes and nose areas are absent but the ears may be seen. This occurs because the center of the retina is the macular and with its degeneration the central vision is lost. It is important to note that the retina surrounding the macular is usually healthy thus the preservation of peripheral vision.
VisionCare Ophthalmic Technologies has developed a telescopic lens which is implanted in the eye and which casts an image on the retina which is almost three times normal size. An image of this size is large enough to be projected onto healthy retina and avoid the degenerated central macular. Studies have shown that there is a substantial improvement in visual acuity and this improvement has been unchanging over several years. Patients who have already received the lens have reported significant improvement watching TV, recognizing faces and facial expressions as well as reading large print books.
The best news is that the lens manufacturers have obtained FDA approval. They are awaiting Medicare approval which is only a formality. At present, candidates for the procedure must have severe vision loss in both eyes and be at least 75 years old. The eye can not have had prior cataract surgery and must be healthy except for the macular degeneration.
Having worked with many patients facing the problems surrounding macular degeneration, I was very pleased to note this major advancement in technology. I will be happy to discuss the possible candidacy for this lens with any interested patient or family member.
Here at Miami Eye Center I am seeing a gradual trickle of RK alumni who had their surgery in the 80’s now coming back for cataract surgery. While the outcome from cataract surgery following prior RK can be excellent, there are a number of important issues that should be understood by the patient. The cornea is a very complex tissue that is perfectly designed to help focus light on the retina and the result of making radial incisions vastly alters the optical properties. Most importantly is that the cornea loses its stability. As the years have past since the RK, the cornea has flattened. In addition, within any given day the cornea shape changes from flat in the morning to steep in the evening. This often makes people farsighted in the morning and nearsighted later in the day. When we make the preoperative calculations for the intraocular lens we are in effect shooting at a moving target. When the calculation is off, the patient will be either nearsighted or farsighted following the surgery. In addition, the algorithms applied to normal corneas are impacted by the flatness of the RK cornea further making the calculations difficult. While I have a pathway of making the appropriate calculation adjustments I still warn patients about the above possibilities. Also that one can not be certain of the outcome until several months following the surgery as the cornea continues to flatten. If the power of the eye is not satisfactory there are several options for improving the outcome. Eyeglasses are easiest but perhaps not the first choice. Contact lenses might be worn. Lastly, it is possible to insert a second intraocular lens into the eye to add or subtract the power necessary to yield good vision without glasses. I have done this on a number of occasions at which time the calculation of the “piggyback lens” is straight forward. I would recommend against a multifocal lens implantation because the multifocals don’t perform well if there is any significant power error. A second reason is that there could be too much glare as a result of the optical properties of the RK cornea combining with the optics of the multifocal lens. In many instances the Toric Lens has been helpful in managing astigmatism that is often seen after RK surgery. It is important that the surgeon understand the type of astigmatism since the lens is not optimally effect in irregular astigmatism. My advice to any post-RK cataract surgery candidate is to be certain that their visual loss is due to cataract and not a cornea related issue and find a surgeon who has been there, done it and has a T-shirt.
For the past few weeks I have seen increasing numbers of patients here at Miami Eye Center complaining of red, itchy eyes. Known as allergic conjunctivitis, this set of symptoms afflicts millions of Americans. The condition doesn’t lead to loss of vision but it surely can impact your quality of life. Folks who have lived here in Miami for any period of time know that there is always some tree that is blossuming with the potential threat of an allergic attack. Recent arrivals are always surprised when their allergy season begins long before it used to when they lived elsewhere.
The first thing that should be understood is that the allergic reaction represents a complex casscade of biological events initiated by the allergen which sets off the response. It is for this reason that eye whitening drops such as Visine and similar products (vasoconstrictors) will not have an effect on improving the symptoms. This class of drops constricts the small blood vessels on the surface of the eye and makes it look whiter. Once the effect of the drug wears off, there is a rebound and the eye gets even more red than in the first place; you get into a never ending spiral. Probably worse than vasoconstrictors is taking oral Benedryl which seems popular in Miami. This drug will put you to sleep and perhaps that will relieve your symptoms but it will have no effect on the conjunctival reaction.The solution to your problem lies in the interruption of the allergic cascade that causes the swelling, itching and reddness. It has been my observation that getting allergy tested has no place in the management of allergic conjunctivitis. Firstly, the tests will not reveal the specific allergen causing your problem and secondly, even if the allergen is discovered there is no method of desensitizing yourself for allergic conjunctivitis as you might for other allergies.
The itchy eyed patient needs to obtain a product such as Pataday, Zaditor, Elestat or Lastacaft which are prescription items. These drugs specifically interupt the release of histamine along with suppression of other biochemical reactions. These drops have few side effects and can be used over the long term.
The “take home message” here is don’t waste your time with over-the-counter allergy eye drops and get a sophisticated product.
First of all you should know why your eye is white then you can better understand why it is red. The part of the eye that holds things in (like the outer cover of a basketball) is known as sclera and its structure gives it a white color. Covering the sclera is the transparent conjunctiva which is thin and filmy and contains blood vessels. In the healthy state, the white sclera shows through the transparent conjunctiva. When these blood vessels enlarge or rupture the conjunctiva is no longer transparent and the eye is red.
When any tissue in your body is inflamed, the blood vessels dilate, blood flow increases and this is the case in the eye. The redness of the conjunctiva varies in color, location and degree with different diseases and this helps me in making the diagnosis of the cause of the redness. Last week I operated a patient at Miami Eye Center who was complaining of cosmetically unacceptable large angular blood vessels in the conjunctiva. In this case they were cauterized. In Miami and elsewhere, when the trees blossom many eyes in town turn pink. This is allergic conjunctivitis and is due to the release of histamines which cause vessels to dilate and leak fluid. You may have tried to open your eyes in the morning only to find them puffy and red. While you are sleeping irritants get caught up in the tears under the eyelids and the body immune system responds by releasing chemicals helpful in the defense of the eye. Here the reaction to those chemicals is a red eye.
Many patients complain of red, burning, stinging dry eyes. Very often the problem is a tear film deficiency, that is, the quality of the tears is poor. Several diagnostic tests will help pinpoint the culprit as a tear film problem. The classic red eye is the “pink eye” or conjunctivitis and is caused by a bacteria or viral attack. Often only one eye is red which helps in the diagnosis but it is difficult to determine if the infection is viral or bacterial in the early stages. Antibiotic eye drops and hand hygiene are very helpful but if one does nothing most conjunctivitis will clear by itself; the question is how long will it take and how miserable will you be during that time.
I see patients who are quite upset when they awaken to find a “stoplight red” eye. This looks terrible but is benign. The most common cause is a sneeze or aggressive eye rubbing which bursts a small blood vessel. Over a week or so the red will fade to green and yellow as the blood is absorbed. Don’t worry about this.
This has been a brief survey into the world of red eyes. It is one of the most frequent reasons for a visit to an ophthalmologist. In many cases the reason for the red eye will be obvious but in many, not so. In any case, don’t use Visine as all that it will do is constrict the blood vessels so your eye looks white but it does nothing to treat the fundamental problem. You are much better trying artificial tears and if that does not help, just give me a call.
Here in Miami, there appears to be some incentive going to pharmacists as they press patients to accept generic substitutes for brand named drugs.This practice may seem fine in the short term as you leave the pharmacy having saved $20.00 on the co-pay but what is the longer term consequence?
One of the most effective eye drops taken by patients following cataract surgery is cortisone.It reduces inflammation, eliminates pain and promotes healing.Over the many years of my practice at Miami Eye Center, I have seen patients given generic prednisilone acetate when I had written a prescription for Pred Forte (prednisilone acetate).What I have seen as a result of this switch is an eye with smoldering inflammation that takes weeks longer to quiet down.You might ask, “What’s the difference, they are both prednisilone acetate?”The difference is the liquid in which the active ingredient is suspended.The brand name drug has a sophisticated formulation that enhances absorption through the cornea, protects the cornea and has a better pH so it does not sting.All this leads to a better therapeutic effect.The FDA does not require the generic drugs to prove their therapeutic equivalence.If you are taking an antibiotic eye drop, you want that active ingredient to penetrate the eye; that is where the generic can let you down.
Be aware of generic glaucoma drops.In Miami, my staff and I battle every day with insurance companies and pharmacies to ensure that our patients are given the brand drug.In this instance we are dealing with a potentially blinding disease.
This is written as a note of caution.When the pharmacist next insists on a generic eye drop, check out the price of the real thing (brand); if you can afford the extra expense then pay it and know that you are getting all the “bang for the buck”
Quite often I find myself counseling a patient about the flashes of light that they see. When this occurs for the first time it is a shocking experience and can be freightening. These flashes can be in the center of the visual field or off to the side. The location of the flash is highly diagnostic of the cause. I am going to discuss the centrally located flashes in this blog and we can discuss peripheral flashes in the future.
Central flashes are always on a vascular basis, ie, they are in some way related to the blood circulation in the eye. The flashes may come in the form of a colored zigzag line or a bright colored blob in the center of the vision. It may gradually grow in intensity over 10 to 30 minutes. This visual aura may or may not be followed by a pounding headache, nausea and vomiting and light sensitivity. Whether there is a headache or not, the cause is the same, a migraine. When there is no headache but only the aura, it is refered to as an ocular migraine or migraine variant.
In my experience the ocular migraine is very often associated with emotional stress. There seems to be an ”epidemic” around the Christmas holidays. While there is no pain, there is a transient loss of vision which can be debilitating especially if you are driving. The way traffic flows in Miami the best thing to do is pull off the road as quickly as possible and wait for the vision to return. I don’t know of any instances where the vision was permanently lost.
The best explanation for the occurence of migraines is that they are due to changes in the seratonin levels in the brain resulting in the constriction of cerebral blood vessels. The constriction causes reduced oxygen supply to the brain and in some way this causes the headache.
Many people having migraines have a family history of this problem. Certain foods trigger the headaches, including aged cheese, nitrates, red wine, chocolate, MSG, aspartame from Nutrasweet and alcohol. Pregnancy, the use of BC pills and the menstrual cycle are associated with migraines.
The best way to manage the migraine is to try to avoid the triggers. Once the symptoms have developed the pain may be managed with aspirin, ibuprofen, ergotamines, or prescription drugs such as Imitrex or Amerge.
If the migraine headaches are infrequent it is probably best to “tough it out” seclusion in a dark room and over the counter medications. When I see folks with symptoms which are incresing in frequency I often make a referral to a neurologist.
Frequently, I speak with patients who are interested in improving the contour of their upper eyelids. They see excess skin and want it surgically removed (blepharoplasty). If one looks closely at their appearance it becomes clear that the problem does not lie in excess skin but rather it is due to drooping eyebrows (eyebrow ptosis). While this may look good on Clint Eastwood (back in the day) it is not an appealing look on most of us.
Before
By raising the eyebrows, the skin of the upper eyelids is secondarily tightened and the issue is resolved. There are several surgical techniques whereby the eyebrows can be raised; a direct browlift requires an incision at the level of the upper eyebrow hairs and is cosmetically unacceptable in my view, then there is the coronal incision across the scalp above the hairline used to pull the frontal region of the face up and thus raise the brows and lastly, the endoscopic browlift. While all three procedures are effective, the first can leave noticeable scars and the last two may be more surgery and recovery time than one wants to undergo.
Utilizing Botox, it is possible to effect an appealing improvement of the eyebrow contour and secondarily the issue of the excess skin of the eyelid is mitigated. When one considers the anatomy of the face and particularly the musculature controlling the eyebrows, one sees that there are muscles that depress the brow and those that elevate them. With the judicious use of Botox, the depressor muscles can be weakened and the apposing elevators will then raise the brows. The technique requires injection at seven sites. While it is not effective in all cases of eyebrow ptosis, this approach when applicable is safe and easy with no down time.
Cosmetic eyelid surgery for the correction of drooping eyelids (ptosis) and/or baggy eyelids (blepharochalasis) does not hurt! Not before, during or following the procedure. That may seem hard to believe and I must agree that unless I had witnessed this phenomenon numerous times, I would not believe it either.
AFTER SURGERY
Preoperative photos are taken and a plan for surgery is discussed with the patient. Firstly, during the procedure the patient is given an intravenous sedation and once asleep the eyelids are anesthetized with Novacaine and adrenaline. When I say “asleep” I mean local sedation which wears off in several minutes unless it is repeated. Some patients are awake enough to maintain a conversation, others prefer to “not know anything.” Any level of sedation is possible. The adrenaline is added to the Novacaine to shrink the blood vessels of the skin and thus reduce bleeding.
During the procedure the excess skin is removed. I prefer to accomplish this with a radio frequency generator transfering the energy to a cutting needle. Some refer to this as “radio-surgery.” The incision is precise and bleeding is minimal, all leading to a rapidly healing wound with little to no scarring. Once the skin has been removed, the underlying fat is excised, this eliminates the baggy appearance. In general, woman require that all the fat be removed as this allows for a smooth contoured upper eyelid which makes the application of mascara and eye shadow much easier.
Lower eyelid surgery requires attention to detail. The contour of the lower eyelid line is important as is the bagginess of the lid. The baggy lids are due to the migration of fat from behind the eyeball to a more forward position. The sagging lower eyelid line may be due to a weakening of the structures supporting the lid. A fine line incision is made below the eyelashes and the fat is exposed and excised. Now that the lid is dropping back to the position that it should assume, the extra skin is removed. The wounds are stitched with a fine synthetic material (Prolene) which is removed in one week.
I discharge patients on the day of surgery with instructions to use ice compresses and return to the office in 24 hours. We never offer pain medication as there is no need for any. On the first day the wound is cleaned and folks are asked to return in a week. They are to use ice for the next few days and at the same time they can be up and around; driving, desk work, etc is O.K.
Bruising from the surgery is related to the amount of bruising that folks normally experience. To minimize the bruising I ask patients to discontinue aspirin and anticoagulants well in advance of the day of surgery. If your medical condition does not allow for the discontinuance of these medications, you are not a candidate for eyelid surgery.
In many instances, I am able to get patients qualified with their health insurance company (including Medicare and Medicaid), to pay for the surgery for the upper eyelids; lower eyelid surgery is usually considered cosmetic and not paid. There are some exceptions in the case of drooping lower eyelids causing tearing (ectropion).
Call the office, come in and let’s talk about your specific situation.
