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.

The eyeball must have an internal pressure in order to function properly just as a basketball needs the proper pressure to bounce correctly.  The normal range of eye pressure is 12 to 21mmHg.  If you press on a healthy eye it will indent only slightly.  Please don’t do this at home.  When the pressure raises above 21mmHg, there is an increased risk of damage to the optic nerve; glaucoma.  There are factors which muddy the water.  Some people have thin corneas and some have thicker corneas, this effects the ability to accurately measure pressure and it effects the eye’s susceptablity to glaucoma.  Using a pachymeter, the cornea thickness can be measured and the normal pressure is adjusted for the individual.  Another confounding issue is that some people with elevated pressure don’t get glaucoma (ocular hypertensives) and some with normal or low pressure do get glaucoma (normal tension glaucoma).  Based on this observation, it is clear that there is more to glaucoma than just eyeball pressure.  But medical science at this moment in time only knows that if you lower eye pressure, patients tend to retain their vision.  Some time in the future we will be directing the treatment at some neural-based regulatory mechanism controlling the circulation in the optic nerve.

Once the diagnosis is made, the question becomes, “how low does this patient’s pressure need to be so as to stop the progression of the disease.”  Not surprisingly, it is different for each individual so the approach is to attempt to lower the pressure by 20% as the initial strategy.  Once the target pressure has been achieved the vision is monitored for further loss of peripheral vision (visual field testing) and the appearance of the optic nerve is checked (optic nerve tomography) for degeneration.  If patients continue to lose perpheral vision and/or optic nerve damage is progressive, the pressure is lowered further.

Pressure control is achieved with one of a number of eye drops which work by reducing the production of fluid within the eye or enhancing the outflow or both.  If one or a combination of drops is not effective then laser surgery might be the next option or possibly traditional glaucoma surgery in the operating room.

In my experience, the majority of patients with open angle glaucoma do quite well with a lifetime of eye drops.  In those people where pressure control is not attainable with conservative means (drops or laser) one must not waste time moving forward with surgical intervention.  This is particularly important in younger individuals with advanced disease.

The eyeball is a closed system with fluid (aqueous humor) continually circulating in and out via a highly regulated structure (trabecular meshwork).  If the production of fluid remains constant and there is a problem with the outflow, the pressure must rise.  The optic nerve connects the eyeball and the brain and inserts itself into the back of the eye.  This nerve is very sensitive to pressure changes and if the pressure remains too high, the nerve becomes damaged.  When damage occurs to the nerve, vision is lost in a characteristic pattern; the periphery of the vision is lost long before the center of vision is effected.  If untreated, the central vision is ultimately lost and blindness ensues.

The most common type of glaucoma is open angle and a less common form is narrow angle or closed angle.  The “angle” refers to the region on the inside of the eye where the clear cornea meets the iris (colored part of the eye).  It is in this angle that the fluid passes out of the eye.  In narrow angle glaucoma the iris bulges too far forward and touches the cornea thus obstructing the flow to the angle.  When this occurs, the pressure in the eye raises very quickly causing severe pain and loss of vision.  It becomes a medical emergency.  This relatively rare situation most often occurs without warning in people who are anatomically predisposed, i.e., they have small eyeballs with crowding of the angle.  Sometimes cataract formation in the presence of a small eyeball can precipitate the angle closure.

Open angle  glaucoma is far more common and occurs as a result of a defect in the trabecular meshwork which is the structure in the angle through which the fluid must pass on its way out of the eye.  So here the angle is open but the filtration mechanism does not function properly.  The net result is that the pressure raises above normal but usually in a much more gradual rate.  Since the pressure raise is gradual there is no pain but damage to the optic nerve nevertheless develops.  Since the resulting visual loss occurs in the periphery, most people don’t realize that there is a problem.  I saw an elderly gentleman in the office who had undiagnosed advanced glaucoma.  He had attempted to drive his car between two side-by-side trucks on a four lane highway since he only saw one of them.  This is an example of how bad the disease can become.

If left untreated the vision loss extends to the center of vision.  This is one of the reasons for a routine ophthalmic examination on a periodic basis.

Treatment options will be discussed in a future blog.

 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.