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”

Most of my patients think that astigmatism is a disease; it is not and it’s time to clear the air.  Astigmatism is a normal condition effecting 80 percent of the population.  Astigmatism is caused by an irregular shape of the cornea; the clear window on the front of the eye is the cornea.  In a non-astigmatic eye it has a round curve in all directions, like a basketball.  In the case of astigmatism, it is shaped like a spoon.  In one direction there is a steep curve and in the other there is a gentle curve.  This is called “regular astigmatism.”  When light passes into the eye it must pass through the cornea.  When there is no astigmatism the light comes to a perfect focus on the retina and the vision is excellent.  When light passes through an astigmatic cornea light from different directions is focused differently and there is a blurry image projected onto the retina.

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.

I have been seeing an increasing number of folks coming in for an opinion about their pterygium.  Most don’t know that is the name of the fleshy-looking growth on the nasal side of the cornea.  It has a triangular shape which looks somewhat like a wing, therefore the name “pterygium” which from the Greek means “wing.”  The pterygium may first appear as a reddish area on the nasal side of  the dark central part of the eye (the iris provides the color and the cornea is the clear window over it) only to grow onto the cornea as a fleshy membrane.  If left untreated, it has the potential to grow across the center of the cornea and result in a severe loss of vision.  It seems that the growth and development of pterrygia are related to sunlight so if you have noticed a small pterygium, get some good quality sunglasses. 

 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.

It is my pleasure to open the BLOG section of this website.  I hope to give the reader an opportunity to obtain up to the minute information about the newest technologies offered at MIAMI EYE CENTER as well as the greater ophthalmic community.  I encourage those with an interest to become involved with questions or comments.

This evening, I was reviewing the chart of patient C.B. who is a very young 72 years.  He had R.K. (radial keratotomy) surgery in Columbia 15 years ago.  He was quite pleased with the outcom of that surgery until recently when became bothered by nighttime glare while driving.  He consulted an optometrist who diagnosed cataracts and referred him to this office.

I began performing radial keratotomy surgery for myopia in 1982, PRK in 1996 and LASIK in 2000.  Now that many of my patients from those days have “grown up” they are developing cataracts.  Cataract surgery in folks who have had prior RK, PRK or LASIK presents a unique challenge to ophthalmic surgeons but one which I have managed incorporating the newest technology.  The challenge facing the surgeon is in selecting the proper intraocular lens to place in the eye at the time of surgery.  For patients who have not had prior refractive procedures, the selection process is routine.  However, the standard computer programs used for the average patient do not work for people who have had prior RK, PRK or LASIK.  If the incorrect lens is utilized, the patient will be nearsighted or farsighted following the surgery.

In the clinic today, I measured the power of C.B’s eye as one would for making eyeglasses.  I then inserted a special diagnostic contact lens and repeated the process.  This yielded the true power of the cornea and that data was used in two additional programs to yield the power of the intraocular lens to be inserted at surgery.  These mathematical manipulations have been evolving over the past several years and I have found them to be quite accurate.

The goal of modern cataract surgery is not only to achieve excellent vision for the patient but excellent vision without glasses.  This goal can be achieved for many patients even in complex cases as outlined here.