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.   

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.

I am asked this question on a regular basis, “are my cataracts ready for surgery?”  The answer to this question is not a “one size fits all.”  Since cataracts develop slowly in most cases, the change in vision is subtle.  Very often, the only way to know that you have developing cataracts is to be told by your ophthalmologist during a routine examination.  In any case, the earliest symptoms are often glare while driving at night, glare during the day, dim vision in low light or double vision.  In all cases this is a painless process.  The symptoms will be different depending on the location of the cataract change in the lens of the eye.

Cataracts which are found in young individuals are often associated with using steroids (cortisone) for extended periods or following eye trauma.  This type of cataract is located in the back of the lens (posterior subcapsular cataract).  Because it is closest to the retina, the impact on vision is most profound; a small cataract can cause substantial loss of vision.  These cataracts tend to develop quickly.  The more common type of cataract is called a nuclear cataract and is the typical age related lens change.  This cataract grows slowly sometimes taking ten or twenty years to become a problem.  There is also an anteriorly located cataract known as an anterior cortical cataract seen quite often in diabetics.  Because it is further forward in the eye and away from the retina, it has less of an impact on vision.

The over-riding factor that determines when it is appropriate to intervene with surgery is the lifestyle of the individual.  Depending upon your line of work or your recreational interests, you will have different visual needs.  I have performed cataract surgery on commercial airline pilots who had only a slight loss of vision with only a small amount of glare.  Their complaints would probably not bother most of us.  But when attempting a landing at night there is an exquisite need for sharp vision and these young pilots were in need of help.  I have operated a number of recreational fisherman whose complaints were not being able to see into the water or see the markers at night.  Golfers ofter complain that their friends can follow the ball and they can not.  At the other end of the spectrum is an elderly inactive person whose only interest is to sit in front of the T.V.  This individual can just move closer to the screen and defer surgery indefinitely.  I hasten to add that I have seen amazing changes come over debilitated folks (who might also have hearing problems and possibly Alzheimers Disease) following cataract surgery and the resumption of good vision.

Most of us are somewhere between the pilot and the elderly infirmed T.V. watcher.  It is for that reason that routine exams are recommended and once cataracts are diagnosed, continued followup is important.  Cataracts are not a disease, they are a normal part of having birthdays.  These days we are all hoping to live well as long as we can and often early intervention with cataract surgery can put spring back in your step.