Cataracts are a clouding of the natural lens in the eye. The lens becomes yellow or opaque preventing light and images from reaching the retina. They most frequently affect older patients, but may appear in younger individuals as well. While the most common type of cataract is age related trauma, oxidative stress caused by drugs, poor diet, environment, and disease or congenital issues may precipitate lens opacities in younger folks. Over the years, surgery to correct this common vision problem has evolved in several dramatic ways.

Early surgical cataract procedures involved the affected lens being removed, and the patient had to wear very thick eye glasses in order to see. This posed several optical problems which were then best corrected with contact lenses. As time passed, the first intraocular lens implant was developed. This early lens was placed in front of the iris, (colored part of the eye), and replaced the natural lens in power to refract light on to the retina. It soon became apparent that vibrations in this implant damaged the inner most layer of the cornea called the endothelium. On occasion this in turn resulted in an opaque cornea and the need for a corneal transplant.

This problem was solved by the next generation of lens implants that were placed behind the iris, and were called posterior chamber implants. They were secured far enough away from the cornea, so that they had no impact on it. These early lens implants were fairly large, and required a large incision to remove the natural lens and implant the new one. As time progressed, Phacoimulsification became the procedure of choice for cataract surgeons. This revolutionized the procedure. A small incision was required, and as a result fewer sutures were needed. Along that time, foldable implants came along that could be inserted into the eye through that small opening.

The next big advancement was removing the cataract, and inserting the implant directly through the cornea. This approach did not require any sutures, and thus healing time was even further reduced as was patient discomfort. The nagging issue that plagued cataract surgeons was to be able to eliminate the need for eye glasses after the surgery. To that end, stronger implants have been developed, multi focal, UV absorbing IOLs and many other options have been employed. Some have worked well, while others have failed. A most troublesome residual problem has been how to correct astigmatism after this surgery. At first, eye glasses had to be worn to correct the uncorrected astigmatism. Then some surgeons advocated making incisions in the cornea to reduce or eliminate the astigmatism post surgically. While this therapeutic approach was fairly successful, most patients did not want an additional procedure if note needed.

Recently, the astigmatic problem has now been solved. The STAAR Toric IOL is now available, and can correct up to 3.50 diopters of corneal astigmatism. That means that most people that have astigmatism before surgery can choose to have this new IOL implanted at the time of surgery, and have their astigmatism corrected resulting in no need for distance eye glasses after the procedure. The implant works similarly to a toric contact lens. When seen in the eye, there are peripheral markings to evaluate the positioning of the lens. The results thus far have been very good with only a few patients complaining about glare. These implants are not covered by most insurance companies and there fore must be paid for by the patient.

Always ask your surgeon about the options for implants before surgery to see if there is something that will best suite any visual needs.

The refractive surgical procedure, PRK involves debrading, or scraping the top layer of the cornea, thereby exposing the inner layers which are then treated with a laser. In doing so, the cornea can be reshaped, and this will improve the vision of the patient. Ideally, the patient will wear a bandage contact lens for several days post operatively while taking anti inflammatory and antibiotic eye drops. Most often the patient’s cornea will heal properly and the corrected vision will be stable, and good.

On occasion, the corneal tissue does not grow back at the desired rate, and nearsighted patients may become farsighted post operatively. In these cases, the outer layer of the cornea may not have fully regenerated resulting in an overcorrection. This condition is called Epithelial Hypoplasia, and is a thinner then required corneal outer layer. The cornea may be as thin as 50-60 microns, 560 microns for a normal cornea, and has difficulty growing back.

Fortunately, there is a procedure to help the epithelium regenerate correctly, and it is called CLAKIS. It is a contact lens assisted procedure, and effectively makes the cornea grow back. The treatment involves placing a soft contact lens on the eye, and wearing it for a week at a time while taking Non Steroidal Anti Inflammatory drops, Voltarin, concurrently. The contact lens creates an inflammatory response in the post operative eye while the Voltarin prevents scarring during the regrowth period. The increased inflammation causes an increase in cell growth, increasing the outer layer and thereby decreasing the hypoplasia. In doing so, the hyperopia (farsightedness) is eliminated.

This procedure is not a well known, or a widely employed therapy. However, it is a very effective solution for the surgical over correction of nearsighted patients. In short, it is very important to always be in the care of a very experienced surgeon so he/she can properly deal with all potential surgical complications, and respond in an efficacious way.

Reduced vision, or even blindness my exist for an individual for a number of reasons. Treatment will depend on what the cause is, and how effective the treatment will be. Conventional, non invasive treatment has always been eye glasses, or contact lenses to correct visual problems. Over time, improved eye glass lenses and contacts have evolved that reduce glare, eliminate unwanted wavelengths of light, improve depth perception, and address many environmental issues.

More recently, there have been new developments in the medical treatment for visual impairments. For example, Avastin a drug that was originally intended to treat Colo-rectal cancer has been found to improve the vision in patients with Macular Degeneration, Diabetic Retinopathy and other vascular related retinal diseases. Non steroidal anti inflammatory drugs can reduce retinal inflammation, and cyst formations. New drugs have been developed to treat infections more affectively.

A major challenge has been therapeutic alternatives for genetic and congenital disorders. These diseases arise from within the patient, and therefore pose limited treatment options. The future appears to be gene therapy. Recent clinical trials performed at the Scheie Eye Institute in Philadelphia using gene therapy have dramatically improved patient’s vision from detecting hand motion to reading letters on an eye chart. These tests were performed on individuals suffering from a congenital disease called Leber’s Congenital Amaurosis. The study was then published in the New England Journal of Medicine. This particular eye disease results from a mutation in the RPE 65 gene. This mutation prevents the gene from producing a protein required in the manufacturing of the retinal pigment epithelium. This protein is required for the retinal tissue to absorb and process the light into vision.

The treatment included injecting a normal RPE 65 gene directly into the retina. Two weeks following the injection, all the patients demonstrated improved vision. In addition, all participants became more sensitive to light. As a result of the increase in acuity, there was a concomitant decrease in abnormal eye movements which further increased the eye’s ability to see.

While these clinical investigations were performed on individuals with a certain congenital disorder, it gives hope to other people with genetic conditions that help is on the way. With any luck, retinal disease will be a thing of the past as these treatment modalities improve.

Amblyopia, or lazy eye is reduced vision in one eye as a result of a sustained period of visual neglect in childhood, resulting in neither eye glasses nor medical treatment improving the vision in that Amblyopic eye. During infancy, an infant’s neurological system is very flexible, and can easily adapt to changing environmental stimuli. As such, during these formative years our visual systems learn how to function. If during that time one eye does not get adequate visual stimuli it will not develop to the same level as the other eye.

As an individual gets older, the flexibility of the system decreases, and after the age of 7-10 years old, much less can be done to improve vision in an Amblyopic eye. The best treatments to date for improving vision in one of these patients has been patching the better eye, forcing the weaker eye to work harder. In doing do, vision improves in that eye. The younger the patient, the better the results can be obtained. In addition, Vision Therapy(VT) should be part of the therapeutic plan as it retrains the visual system to function correctly. VT has a very high rate of success when done properly.

The problem has long been that after a certain age, due to the lack of plasticity of the aging visual system, an Amblyopic eye was not able to regain adequate vision. New research appears to have changed Amblyopia treatment.

The antidepressant medication Prozac, has been shown with continuous administration to reinstate ocular dominance plasticity in adulthood. This can promote improved visual function in older individuals. In early childhood the neuronal connections are very plastic, but as the critical period closes, this flexibility is greatly reduced. According to research published in an issue of Science Magazine, treatment with Prozac reopens the critical period of plasticity in the visual cortex, and Lateral Geniculate Body parts of the brain. These studies were done in rats only. In order for this flexibility to be reopened, the good eye must still be patched for a minimum of several hours per day.

The researchers concluded that the restored plasticity with the use of Prozac was as a result of a reorganization of neuronal connections in the cortex. Furthermore, maximum visual improvement was achieved when Vision Therapy was also administered. The only concern that the researchers revealed was what side affects would be with long term use of the drug. To date, known affects include but are not limited to suicide, severe anxiety, glaucoma, and visual filed defects. Future, long term research needs to be done to determine the risk/benefits of such treatment.

Over the counter remedies are all thought to be very safe; since a doctor’s prescription is unnecessary. That however, is not true. All medications, whether they are prescribed or not, have side effects, and can react with other pharmacological entities. In some cases, these effects could have very detrimental consequences. As an example, drinking grapefruit juice when taking cholesterol lowering medication affects the metabolism of the medication, and can create a toxic environment. Further, milk neutralizes the antioxidant affect of tea, and facial creams can raise eye pressure.

The blood supply of the scalp is shared with that of the forehead, and eye lids. Any products applied to the head, or scalp can be absorbed into the blood stream, and ultimately get introduced into the eye. One such potential complication is hair coloring chemicals. We have seen on numerous patients, eye irritations, and allergies on women who have had their hair colored. The chemicals travel from the scalp to the eye lids into the eyes causing a negative reaction.

A much more serious issue is the use of steroid cream frequently used by Dermatologists. Most of the time, this cream used for the treatment of allergies, dermatitis, and even to reduce wrinkles. However, a recent study conducted in Concord, North Carolina concluded that ” ….although secondary ocular hypertension from topical steroid eye lid cream is unlikely, it is possible that enough of the drug is absorbed into the eye in sufficient quantities to raise the intraocular pressure in a steroid responder.” What this study found was that in certain individuals, the steroid cream can cause the pressure in the eye to rise, and ultimately cause damage to the eye if left untreated.

Steroids have long been used in the eye to treat inflammation, but only when carefully monitored. When such medications are employed near the eye, but are not carefully followed, can raise the pressure and cause Glaucoma. A similar study described a 29 year old woman being treated for Eczema for many years who ultimately went to her eye doctor with glaucoma in both eyes, and irreversible vision loss attributed to the steroid creams used around her eyes.

In short, it is very important for patients to realize that all medications may have secondary affects, and can cause disorders not related to the conditions they are being treated for. It is vital to understand any potential side affects, and follow up with related health care professionals to be sure the medications being taken are not creating collateral disorders.

As we age, there is an increase in many disorders, and the physiological changes that make those diseases worse. Like wise, there is an increase in frequency and severity of neurological conditions affecting the brain with age. One such condition is Lewy Body Disease. This is of particular interest to me because of 2 reasons. The first is obvious. My name is attached to the disorder. While I have a rare name it is shared with a famous researcher of the early 1900s. The second is that my wife is convinced that I either have dementia or just do not listen to her.

While most doctors are not familiar with a condition called Lewy Body Disease, it is the second most common cause of dementia resulting in as much as 20% of all cases. This is according to the Lewy Body Disease Association. There is no cure for this condition and does worsen with time.

Lewy Body Disease is comprised of a spectrum of symptoms involving dementia and motor abnormalities. Diagnosis is difficult because the dementia is similar to Alzheimer’s or Parkinson’s but differs in that LBD does demonstrate strong psychotic hallucinations, extreme sensitivity to antipsychotic medications and the disease varies from day to day. Furthermore, LBD is twice as likely to occur in men as women unlike Alzheimer’s which is equal in both sexes. There is also no genetic link.

Lewy Body’s are abnormal microscopic protein deposits located in the mid brain and found in nerve cells that disrupt the brain’s normal function. This results in the deterioration of the brain over time. It was first discovered by Frederick Lewy in 1912 a colleague of Alois Alzheimer. It has long been known that the presence of Lewy bodies is a hallmark of Parkinson’s; they were discovered in the cortex in the 1960s and affiliated with dementia. People with LBD have the protein bodies in both the mid brain and the cortex which severely impairs the functioning of the brain.

Signs of LBD include mental decline, recurrent visual hallucinations, poor response to antipsychotic medications, difficulty with daily living activities, sleep disturbances and fluctuations in autonomic processes like blood pressure, temperatures swallowing and bowel movements.

Diagnosis is difficult; it requires an autopsy which makes it more difficult in the living patient, but a well trained physician can differentiate this disease from Parkinson’s and Alzheimer’s.

Sincere there is no treatment for this disease, diagnosis does not really help the patient cope with the eventual symptoms, but at least knowing what is happening may help in future cures. The visual disturbances, and hallucinations are the links to my series of articles. Many patients will come in saying that they see things. Knowing that there is another possible diagnosis is helpful to at least the patient’s family.

As for me, I can at least tell my wife that I have a reason for acting strange and blame it on my name sake of 1912.

In an effort to stay healthy, and prevent disease many of us have been taking vitamins. When examining the physiology of our eyes, it makes sense in certain instances to supplement our diets, and improve the metabolism of tissues. There are several problems that arise with that point of view. The first; is that many of these supplements have not been proven to be useful. The second; is that there can be drug interaction between the vitamins and other medications. Therefore care must be taken, and always inform your doctor of anything that you take.

Many studies have suggested that taking Vitamin E will prevent cataract formation. As such, many seniors have rushed out and started taking this fat soluble supplement. However, a recent 10 years study published in the May issue of Ophthalmology concluded that there is NO benefit in taking the vitamin E with regard to preventing cataracts. The study followed over 37,000 women and found no difference between those taking the vitamin and those that did not.

Cataracts form when the internal lens of the eye becomes yellow as a result of Ultraviolet light absorption. This high energy light transforms a type of protein in the lens making it less transparent. Previous studies have found that taking Vitamin C will block this transfer of protein types, and can reduce the severity of the cataract. One must always balance the intake of any supplement with toxicity. Too much Vitamin C can cause kidney stones in those that are predisposed.

We always recommend that patients wear quality sunglasses which will protect the eyes from the UV light, avoid cigarette smoke which increases the protein transfer, and eat a well balanced diet. In doing so, individuals will get all the nutrients that one needs. Taking supplements is a good idea if there are certian medical conditions or needs, but to most Americans a good diet is all that is needed.

Dry eyes are a serious and growing concern for millions of individuals. The eye must be bathed in a continuous flow of a tear film that consists of several components. A healthy tear film contains lipids, aqueous, and mucin. The outer lipid layer prevents evaporation, keeping the inner layers intact. The aqueous component is a mixture of proteins, mucin and electrolytes. The mucin provides viscosity; enhancing the stability of the tear film. The mucin is in its highest concentration the deeper into the tear film one goes.

In dry eyes, there tends to be a lower concentration of proteins in many cases. The water soluble part of the mucin also tends to be in much lower concentrations as well. These deficiencies tend to promote inflammation, and degrade the stability of the eye. Electrolytes tend to increase in volume as well, which furthers the dry eye problem. Since dry eye symptoms can be varied, the condition is often under diagnosed.

According to the Achives of Ophthalmology 14.4% of Americans report dry eye symptoms, and that increases with age. 8.4% of people under 60 years of age report the discomfort of dry eyes, while 19% of folks older then that do. It is a progressive disease. Individuals that undergo Cataract and Refractive surgery report worsening symptoms, due to decreased corneal sensitivity. In addition, damage to the tear producing Goblet cells cause additional compromise in tear production and quality.

Diagnosis based on symptoms includes discomfort, dry, sandy feelings, burning, light sensitivity, and blurry vision. Important testing to confirm the disorder includes evaluation of the tear film and cornea with Lissamine green and Rose bengel, Fluorescein staining, Schirmer tests, tear meniscus and Corneal staining. The process is simple. Irritation triggers inflammation which is followed by tear deficiency and instability.

Therapeutic goals include increasing tear production, and the quality/components of the tear film. To that end, the first step is the use of artificial tears. They come in a variety of formulations starting with basic low viscosity drops, and extending to thicker Gel drops. The thicker the drop the better it covers the corneal surface. However the down side is that they also will blur the vision as they get thicker. In more severe cases Gels/ ointments are employed to keep the eye covered for a longer period of time. This enables the corneal surface to regenerate and heal.

In worse cases of dry eye, topical steroid drops are used. This reduces inflammation in the tear producing glands such as the Lacrimal Gland. Often they are used for up to 3 weeks in conjunction with the artificial tears. If further therapy is necessary, Restasis is used to increase tear production. This is essentially Cyclosporin which is an anti-autoimmune medication. It is affective, but must be used twice per day for at least 3-6 months, and often longer.

A new development in the treatment of dry eyes is better care of the eye lids. It has now been confirmed that lid inflammation, Blepharitis, reduces tear production and quality. As such, improving this important area has emerged as a focal point of treatment. A new antibiotic called Azasite is now used to kill lid bacteria, and clean out invasive organisms that inflame the lid margin. It is used twice a day for 2 days followed by once a day for a week. Many eye care providers also advise using it once a day for the first day of very month for 6 months. In doing so, it maintains good lid hygiene. Since dry eye is a chronic condition, therapy should be geared for the long haul.

In the most extreme case we now insert Puntal plugs into the lid ducts in an effort to keep all the tears in the lower lid area, increasing the tear meniscus. It has dramatically improved many symptoms, and helped heal the ailing corneas.

In summary, dry eyes are a common, and chronic condition that requires aggressive treatment in order to prevent long term damage to the eye, and improve patient comfort.

Blepharitis is the inflammation of the lids, and it affects the glands that reside within these tissues. The incidence of lid infection ranges from 3.2% in young adults and increases with age to 71.1% with seniors. The cause of Blepharitis is almost always bacterial in nature, and tests positive in cultures. The bacteria grow in the lipids (fats) of the gland, and produce enzymes that break the lipids down into soaps and fatty acids. These 2 byproducts disrupt the tear film causing dry eye symptoms, and all the discomfort that follows. In some cases there is even a microorganism that attaches itself to the lashes called Demodex Folliculorum. Regardless of the cause, the result is red, painful lids and dry eyes.

The diagnosis is made during an eye exam, and some of the clinical signs are collarets around the lash bases, gland obstructions on the lid margins, red crusty lids, and waxy discharges on the lids. In addition, Chalazion is seen in the lids, and inflammation on the cornea as well as marginal ulcers at the cornea/limbal region.

The etiology or cause of Blepharitis can be from Staphylococcal bacteria, Seborrhea, allergic, Psoriatic and even start in the glands themselves. Meibomitis is the inflammation of one of the primary lid glands that produce a tear component. The major problem that occurs with Blepharitis is that the bacteria break down the enzymes, disrupting the tear film. This in turn irritates the eye and the cycle begins of red, painful eyes and in turn red, painful lids.

The goal of therapy is to alleviate the signs and symptoms, but will not cure the condition. Blepharitis is a chronic condition that will require on going maintenance, and treatment for many years. It most often will reoccur. The acute phase of treatment is to bring the condition under control, and improve comfort and appearance of the lids and eyes. The chronic treatment is to maintain control and keep the lids healthy.

The most important part of the therapy is to simply clean the lids. This is done with a soapy solution of diluted baby shampoo and warm water. This solution is employed to clean the lid margin twice per day with a Q tip for at least 2 weeks. Each cleaning must be followed by warm compresses, and gentle lid massage. The warm compresses dissolve the waxy build up on the lids, and the massage removes it while increasing blood flow to the affected areas. In addition, topical antibiotics are always added. The newest and best one is called Azasite. It is Zithromycin in drop form. It is used twice per day for about 3-4 days, and then once per day after that. In addition, another medication is now often added to increase tear production. Restasis decreases inflammation in the tear producing mechanism, and thus increases tear flow. This medicine must be used twice per day for at least 6 months and perhaps even longer. Once the acute phase is treated, then only the Restasis, and once per week lids scrubs are employed.

If a very severe case is encountered then oral antibiotics may be used as well. Doxycycline has been shown to be the best for this condition.

Blepharitis is a long term problem, but when properly treated and managed; patients can be free of many of the dry eye, lid and painful symptoms. Compliance can become an issue because of the long term care required, but good results and appearances are the reward.