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”

Vision is a critical part of sports performance.  At the elite level of sports, the athletes tested have been found to have above normal visual acuity.  It is not only acuity but the entire visual system including association areas in the brain dealing with the visual response which are special.  When a pitcher delivers a pitch at 90 miles an hour, the batter must react almost immediately.  The interesting factor is that once the eye sees the release of the pitch, it takes two-tenths of a second for that visual information to arrive at the visual cortex at the back of the brain.  By the time the brain perceives the pitch, the ball has already traveled 25 feet toward the batter.  Ofcoarse, the same considerations apply to reaction time on the tennis court. There is no doubt that there are numerous immeasurable clues that the batter or tennis player processes in order to get to the ball.  One physical finding that is readily measurable is the visual acuity of the professional baseball player.  Many of the outstanding batters have acuity which is far better than 20/20.  A batter with 20/10 acuity can see the stitches on the baseball as it is released by the pitcher.  This enables him to predict the type of pitch (curveball, slider) that is coming his way.

If there is an athlete in your family, he or she should have their visual acuity measured and the examiner should not stop at correcting the vision to 20/20 but should attempt to correct the vision to the very best that is possible.  A nearsighted baseball player might require the smallest amount of additional power in the eyeglasses or contacts to get to 20/15 and this could make all the difference at the bat or on the tennis court.  Of coarse here in Miami where the glare is so intense, any residual refractive error can enhance the glare as well.

I take this same approach with the senior sportsman/sportswoman who are coming to cataract surgery at Miami Eye Center.  Whether they are avid golfers, tennis players, sports anglers or pilots, these folks need an optimum visual outcome.  This means selecting the best intraocular lens for that individual, meticulously obtaining the most accurate preoperative measurements on that person’s eye and delivering an outcome which exceeds the patient’s expectations. 

A professional fishing guide needs optimum contrast sensitivity and minimum glare.  While it would be nice to offer a multifocal lens in order to eliminate glasses, this would not be the best choice; rather an aspheric lens would fulfill the guides requirements.  And if there is any astigmatism, that must be addressed.

If you are an up and coming athlete or a more seasoned veteran, have your visual acuity optimized, it will make more of a difference than you might think.

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.

During the preoperative examination at Miami Eye Center, we look at the tear film using new technology and are able to determine if you have a deficiency in the water component of the tear film or if your tears are evaporating too fast.  When found, patients are treated with artificial tears preoperatively and the surgery itself is performed in a way which protects the surface of the cornea.  If we find an inflammatory problem causing a tear film deficiency we treat that with a course of cortisone eye drops before the surgery.  We might also use Restasis to decrease inflammation. In cases of eyelid inflammation a round of oral antibiotics as well as antibiotic eyedrops over a period of several weeks can improve the tear film.

The take home message here is that there are subtle issues which can impact the outcome of your eye surgery that are beyond just having a good procedure and your surgeon needs to evaluate these factors and discuss them with you.

Hemaglobin A 1c (HbA1c) is the correct way to assess the level of blood glucose.  The test measures the average level of glucose to which the blood cell has been exposed over its life so you are getting a summary of the blood sugar, not a momentary view as you would get with a single blood sugar measurement.  Patients with type 2 diabetes should have a HgbA1c of 6% to 7% (normal levels are 4% to 5.9% in healthy people).  In addition, blood pressure should be maintained below 130/80.

Studies have demonstrated that very small differences in the management of the disease can have a profound effect on the vascular complications of diabetes.  One study (Diabetes Control and Complications Trial) showed that in a group of young diabetes managed in the usual way with glucose measurements and insulin injections twice a day versus a group having measurements three times a day with accompanying insulin, there was a five times greater risk of worsening of the diabetic retinopathy.

People with diabetes should have an ophthalmic exam once a year.  If they develop mild to moderate retinopathy the exam should done every six months and every two to four months if the vision has been effected by macular edema or prolifertive retinopathy.  While the exam should include measurement of the vision, it is not always an effective way to determine the condition of the retina.  This is because there are many factors which effect the vision other than the diabetes.  If there are any signs of progression a fluorescein angiogram should be obtained.  This is a photographic assessment of the retinal blood vessels.

There are numerous trials under way to identify the best means of treating diabetic retinopathy but the gold standard at this time is panretinal laser photocoagulation (PRP).  This technique creates numerous small laser burns in the retina and has been shown to slow or stop the progression of the disease; it will not undo prior damage.  This technique has been around for forty years, the only change has been the light energy delivery system.  In my training at Medical College of Virginia, some of the pioneering work was being done.  In the early years, the light energy was collected from a huge airport searchlight and narrowed down to a fine beam that would pass through a pupil and into the eye.  Now an Argon laser is the size of a desktop computer.

Studies have shown that only 7% of diabetics reach optimum control of HbA1c, blood pressure and cholesterol and so there is a good chance that an effected patient will worsen over time.  It is therefore important that diabetics seek out quality eye exams on a regular basis.

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.

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.

Something to consider; laser surgery to reduce the pressure and thus allow you to eliminate all or some of your drops.  ALT, argon laser trabeculoplasty which I began doing in 1982, has long been the standard for low risk laser reduction of eye pressure.  It has more recently been supplanted by SLT or selective laser trabeculoplasty.  Patients with open angle glaucoma are candidates for the procedure.  The laser (Q-swithced Nd:YAG) fires a fine beam in 3 nanoseconds which is much faster than you can blink (1/10th of a second).  The patient is seated in front of the device, the eye is anesthetised with drops and approximately 100 laser spots are made taking about 10 minutes.  You can drive into the office and drive home; there are no restrictions.  There is a delay in effect so patients must use their regular drops for awhile following the procedure.  I have not experienced any serious complications; there might be a temporary rise in pressure or no effect at all.  In general, the pressure is reduced by about 4-5mmHg which may be enough to eliminate some or all of your medications.  In addition, the procedure can be repeated when necessary.

This approach may not be for everybody but with the spiraling cost of drugs and the availability of insurance coverage for SLT, this may be a new way of looking at your glaucoma management.  I might add that in many locales, patients are offered SLT when they are first diagnosed with glaucoma and thus avoid any drops from the get-go.

Regular astigmatism is easily corrected with eyeglasses or contact lenses.  If you hold your glasses out in front  of you and look at a picture on the wall while rotating the glasses you might see some changing distortion; this is the lens correcting your astigmatism.  Rigid gas permeable (hard) contacts are excellent at correcting astigmatism while soft lenses are less effective.

There are excellent surgical techniques for the correction of astigmatism.  The oldest method that I began using in 1982 is astigmatic keratotomy.  Here small straight incisions are made on the cornea across the steeper curve (meridian).  This tends to flatten that meridian and steepen the flatter meridian, ultimately making the cornea more spherical.  Along came LASIK where after several years there emerged an algorithm for the correction of astigmatism along with nearsightedness and eventually along with farsightedness.  Very substantial amounts of astigmatism can be corrected with LASIK.  More recently, we have added a variation of astigmatic keratotomy (AK), known as limbal relaxing incision (LRI).  Here the corneal incision is moved to the outer edge of the cornea and is curved rather than straight.  It is more predictable than AK. 

When patients come for cataract surgery we always evaluate their astigmatism.  This is done so that we can calculate the power of the lens to be implanted at surgery and also to be in the position to offer them an opportunity to have the astigmatism corrected with LRI at the same time.  The purpose is to enable patients to achieve excellent vision without glasses when the cataract surgery is done.  We usually reserve the LRI for small amounts of astigmatism because there now is available the toric lens.  This is an intraocular lens with optics designed to neutralize the astigmatism along with the correction of myopia or hyperopia.  This lens is implanted just as any lens might be then it is rotated into a position to match the steep meridian on the cornea, thus neutralizing the astigmatism.

So don’t be concerned when you learn that you have astigmatism; it could be a lot worse.

Something to consider; laser surgery to reduce the pressure and thus allow you to eliminate all or some of your drops.  ALT, argon laser trabeculoplasty which I began doing in 1982, has long been the standard for low risk laser reduction of eye pressure.  It has more recently been supplanted by SLT or selective laser trabeculoplasty.  Patients with open angle glaucoma are candidates for the procedure.  The laser (Q-swithced Nd:YAG) fires a fine beam in 3 nanoseconds which is much faster than you can blink (1/10th of a second).  The patient is seated in front of the device, the eye is anesthetised with drops and approximately 100 laser spots are made taking about 10 minutes.  You can drive into the office and drive home; there are no restrictions.  There is a delay in effect so patients must use their regular drops for awhile following the procedure.  I have not experienced any serious complications; there might be a temporary rise in pressure or no effect at all.  In general, the pressure is reduced by about 4-5mmHg which may be enough to eliminate some or all of your medications.  In addition, the procedure can be repeated when necessary.

This approach may not be for everybody but with the spiraling cost of drugs and the availability of insurance coverage for SLT, this may be a new way of looking at your glaucoma management.  I might add that in many locales, patients are offered SLT when they are first diagnosed with glaucoma and thus avoid any drops from the get-go.