GOING STRONG AT 93

HOW LONG WILL MY CATARACT IMPLANTS LAST?

I guess back in 1983, Mrs. S. asked the same question.  That was the year that she had her first cataract removed here at Miami Eye Center.  She followed with the second eye a year later.  Ten years after that, in 1993, she had a corneal transplant in the right eye.  Here she is pictured during this week’s exam with vision of 20/30 in each eye without glasses.  She is a healthy and active 93 year old.

There are several messages here: (1) If you are in your 60’s and worried about impending cataract surgery know that you and your surgery outcome may well be around for a good long time to come (2) intraocular lenses are composed of a highly refined acrylic which does not appear to degrade over time.  (3) don’t let your quality of life suffer due to poor vision from cataracts.

I have operated well over 15,000 cataract surgeries, evolving my surgical technique as the technology has improved.  I can offer you the latest multifocal intraocular lenses designed to eliminate the need for reading and distance glasses, toric lenses which correct astigmatism or traditional generic lenses.  I can help you choose the best approach for your visual needs; one size does not fit all.  So give the office a call and we can discuss your situation.  I must admit that I will not predict what you will be doing at 93.

The macular is the very center of the retina and when there is damage to this area there is loss of central vision and a preservation of peripheral vision.  The important point here is that the retina surrounding the macular is healthy and functional.  If a person with macular degeneration looks at your face while standing in front of you, they will not see your eyes or nose but will see your ears because the image of your ears falls on healthy retina.  Needless to say, this is debilitating and frustrating. 

Along came VisionCare Ophthalmic Technologies, a research and development company that has developed and tested a lense that is implanted in the eye at the time of cataract surgery which magnifies the light image entering the eye by almost three times and projects an image on to the retina  outside the macular region and on to normal retina.  This lens has been studied for the last two years and it has been found that 60% of the patients had substantially improved vision with significant increases in quality of life.  They had less difficulty watching TV, recognizing family and friends, seeing facial expressions and reading large print books. 

The good news is that that this lens technology has obtained FDA approval and is now awaiting approval by Medicare.  At present this lens is approved for patients with cataracts and severe vision loss in both eyes from dry macular degeneration.  The lens is implanted in only one eye.

Here in Miami, I have been helping patients with both wet and dry forms of macular degeneration for quite some time.  To this point, there has been little to offer those with the dry type of the condition other than nutritional supplementation.  This lens represents the first significant help to come along.

If you are interested in discussing this technology and how it might be of help to you, call me at Miami Eye Center and I will be happy to bring you the full details of this exciting breakthrough.

When your headlights flash an animal in the road you see the bright orange reflex of light from the retina (pictured to the left).  While that was man’s first image of the interior of the eye the view is now down to the microscopic level.  The device which makes that possible is Optical Coherence Tomography or OCT. We can visualize early and subtle changes in the retina and optic nerve in many cases before they are noticed by the individual.

How is this done?  The patient is seated before the OCT machine and waves of safe invisible ultraviolet light are beamed into the eye.  The light is reflected back just as it is with the headlight.  The reflected light is captured by a sensing devise (interferometer) and passed along to a computer which interprets the variations in the reflection as various anatomic parts of the retina and optic nerve.

Anatomic Details of the Retina The complex structure of the retina, pictured here, passes the visual information along its nerves to the Optic Nerve which in turn feeds the image to the brain.  All this processing takes about 2/10ths of a second.  Needless to say, small anatomic problems in the retina can cause big problems with the vision.  So it becomes important to view the anatomic changes asssociated with disease early in their evolution.  This can also be said about diseases of the Optic Nerve such as glaucoma.OCT Image of the Retina

To the practiced ophthalmologist, the image to the right represents all the layers of the retina in sideways view.  One can see early signs of macula degeneration, swelling due to diabetes or other circulatory problems as well as impending holes.

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”

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.

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.

Here in Miami and probably elsewhere, about half of my patients having cataract surgery also have dry eyes or eye allergies or various types of inflammation of the eyelids.  It is amazing to me how this problem can reduce the good results of well done cataract surgery (LASIK surgery as well).  In many cases the condition is only slightly bothersome prior to surgery, however, when you have cataract surgery with one of these ocular surface diseases present, there appears to be a surprising diminusion of the visual outcome.  If you have chosen to make a significant “lifestyle enhancement” with a multifocal lens insertion at the time of cataract surgery you want to maximize the result and achieve the ultimate potential of this new technology. 

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.

Diabetes can have a devastating effect on vision if it is allowed to progress unchecked.  There is emerging new information about the best ways to manage the condition.  Clinical studies have shown that the proper control of blood sugar levels as well as blood pressure and cholesterol can delay or even stop the progression of diabetic retinopathy. 

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.

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.