Cancer is always a devastating condition that has many affects on multiple organ systems. While most people are focused on the location of the lesions, their affects on other areas of the body can be equally disruptive.

A 70 year old, white, woman who has been a patient of mine for over 10 years has been treated for Breast and then Colon cancer. At first, the systemic medication seemed to have little affect on her eyes. After approximately 6 months of treatment she began complaining of dry eyes, decreased vision, and contact lens intolerance. In addition, she stated that her eye lids were red, crusty, and painful. At first, it appeared as though her eyes were a little dryer as a result of the cancer medications, and we advised lubricating drops as needed. When that did not decrease her symptoms, we added Lotemax which is a soft steroid which reduces inflammation and helps the dry eyes. Omega III was also recommended to increase tear production. This nice woman is a very compliant patient so when she returned with no improvement in her condition, we knew we had something else to deal with.

Careful lid evaluation determined that she had chronic Blepharitis which is an inflammation of the glands in the lid. Apparently, the cancer treatment had damaged the glands in her lids. This in turn caused a decrease in tear production and additional inflammation. Thus, the lid condition was the cause of the dry eye, pain and redness. Furthermore, this blurred her vision since the cornea was not moist. Also, the medication had caused her cataracts to develop.

Now that we had the correct cause of her symptoms we had to treat her. Contact lens wear is very difficult when the eyes are dry. The only answer is to wear Gas Permeable lenses that are resistant to dry conditions. So we fit her with a progressive aspheric lens which corrected her near and far vision, and did not cause discomfort with the dry eyes. She did use artificial tears occasionally, but had stable vision. In addition, we instructed her to use Tobradex ointment on her lids at bed time. This is a steroid/antibiotic combination which reduced the inflammation and killed any bacteria that may have set up shop in/on her lids. Furthermore, she cleaned her lid margins with diluted baby shampoo twice per day to remove any mucousy build up and debris that may have accumulated at the gland openings. This was followed by warm compresses to increase blood flow to the area.

After 3 weeks of this regimen she demonstrated noticeable improvement in comfort, lens wear and vision. As a long term treatment she must still clean the lids biweekly with the shampoo and occasionally use the ointment at bed time.
As long as the underlying cancerous condition exists she will not be perfectly comfortable, but our goal is to get her as happy as possible during this difficult time.

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A 37 year old white female patient of ours came into the office with a chief complaint of dry, stingy eyes. She had been a contact lens wearer for many years with few if any complaints, and rarely complained about any problems. She stated that upon awakening her eyes were very dry, painful and red. She had been fine until approximately a month prior. Clinical evaluation revealed that the inferior cornea was very dry, swollen and irritated.

Speaking with this nice young woman revealed that she had been in the hospital the prior month for surgery to correct an Acoustic Neuroma, which is a benign tumor of the inner ear. Treatments for Acoustic Neuromas include laser surgery, invasive surgery, or following the condition. Since they are benign and often never grow, frequently are just followed. Her physician decided to operate to remove the tumor. In doing so, he damaged the 3rd cranial nerve affecting her ability to completely close her right eye. As a result, she was unable to complete the lid closure resulting in the inferior part of her cornea becoming swollen and irritated. In addition, when she slept, the eye remained partially open causing that part of the cornea to dry out. Upon awakening the eye was very red and painful.

Treatment options for the dry eye and corneal irritation included wearing a bandage lens which was ruled out because the eye was so dry or lubrication and medication giving the muscle paresis time to resolve. I chose the second option since it usually resolves the problem most affectively. She was instructed to use Refresh PM, an ointment at bedtime in that eye and tape the eye closed. In addition, she was prescribed Lotemax which is a mild steroid to reduce the swelling. This was done for 2 months until the inferior cornea completely healed and she was able to open the eye with out pain. During that time the 3rd nerve paresis improved approximately 50 % resulting in her being able to close the eye completely and sleep with it closed with out tape.

On a follow up visit she displayed a normal cornea, no redness and no dry eye. She was told that she could wear her contact lenses up to 6 hours per day, but still had to use copious amounts of tears to continue the comfort.

This is an example of an unrelated medical issue causing an eye problem that could have resulted in a damaged cornea and permanent scarring. With proper care and follow up she was completely healed and was free to resume her normal life.

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Diabetes Mellitus is a systemic disease whereby the body produces little or no insulin. Insulin metabolizes glucose and keeps a careful balance of blood sugar. It is a disorder of time and the longer that some one has it, the greater the likelihood of systemic changes.

As time passes one of the major problems with Diabetes is that the blood vessel walls become weaker and begin to leak blood. As this occurs less blood gets to the end organ and that organ system will function at a reduced capacity. For example, if the blood vessels going to the liver are affected then it will have a reduced ability to filter the blood’s waste products. As such there will be an increase in metabolic waste in the blood and can cause a septic toxicity. Also, there will be less bile produced and there fore fat digestion would be affected. So it is easy to see how Diabetes can affect the digestive system, the blood and an organ. In addition, as the vessels leak they cause damage to the surrounding tissue.

With regard to the eyes the damage can be severe. The first change that occurs is called Diabetic retinopathy. It appears as small hemorrhages in the retina. They usually occur with small vessels and most often not before having had the disease for at least 10 years. As the disorder continues it advances to Pre-proliferative retinopathy. This appears as larger hemorrhages and some exudates which are deposits of materials out of the leaking vessels. It indicates a more severe level of Diabetes and results in damage to the surrounding tissue. Next up is proliferative Diabetic retinopathy. In addition to the already mentioned findings, cotton wool spots occur. These are white cloud like lesions that indicate death to the tissue where there was hemes and/or exudates. In addition, larger blood pools occur in the retina and may even fill the eye with blood. This is called an ” Eight Ball Eye.”

A secondary finding is neovascularization. When blood vessels leak, the tissue becomes deprived of the nutrients and oxygen that it requires to function. As a result, small imature blood vessels grow to replace the damaged ones. These new vessels often grow in bad places and frequently break themselves and cause more hemorrhages. There are two most common locations for these neovasculatory vessels. Ths first is under the retina. This most often lifts the retinal tissue and may lead to retinal holes and detachments as well and decreased vision. The second is in the front of the eye between the iris and the cornea. These vessels grow in the iris and into the anterior angle where the aqueous fluid leaves the eye. This is called Rubeosis and is a very bad finding. It usually indicates an advanced Diabetic condition with many changes both in the eye and the body.

Treatment for these ocular conditions involves lasering the affected areas to stop the bleeding and better control of the systemic condition. Unfortunately, it effectively is playing catch up and treating the symptoms not the disorder.

The best way to prevent these Diabetic changes is to control the blood sugar from the start and keep the body healthy from the get go. In addition, see your eye doctor at least once a year, have a full dialated eye exam and if there are any visual changes see him as soon as possible.

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Contact lenses have been worn by millions of people for many years, and most of the time presents no problems. When proper hygiene, care and common sense are employed the risk of serious complications are minimal at best. However, very serious issues arise when patients become lazy, complacent and non compliant.

All contact lenses will cause the cornea to become swollen during the normal wearing schedule. Better quality lenses will create less edema and conversely poor quality lenses cause more swelling. However, the problem is always reduced or eliminated by simply removing the contacts. Individuals that wear their contacts all waking hours are at a substantially higher risk of swelling related corneal problems then those who limit their wear to 12 hours or less per day. In addition, people that sleep in their lenses are almost guaranteed of developing serious eye problems caused by the contact lenses. Chronic swelling is always bad, and leads to such things as neovascularization (blood vessel growth in tissue where it does not belong), separation of cells with in tissue, infections and ulcers.

Over wearing contact lenses is a time bomb waiting to go off. In addition, with regard to disposable contacts, when the FDA determines how frequently a lens should be replaced it is not at random. They follow the oxygen flow through the lens and when the amount of oxygen drops below what the eye needs to function properly the lens must be disposed of. Wearing the lens longer then that time period will result in oxygen depravation to the cornea and physiological changes that are always bad. Unfortunately, there are many folks that think since the lens feels alright that they can keep the lens in the eye until it hurts. That is equivalent to keeping a rock in ones shoe until it causes a blisters. Furthermore, there are those people that are simply cheap and will stretch a lens wear out for months to save money. Those are people that should not wear contact lenses since their attitudes will ultimately hurt their eyes and may even cause permanent vision loss due to their ignorance regarding proper lens wear.

The major issue at hand results from over wear resulting in corneal ulcers. With excessive lens wear the cells in the cornea begin to separate leaving spaces between the cells. These areas reduce corneal sensitivity and open areas ripe for bacteria to hide and grow. A colony of these micro-organisms set up camp and begins to proliferate, breaking the barrier of protection for the eye. Due to the decreased corneal sensitivity the pain is not felt for days, weeks or even months at which time major damage may already be done. As the ulcer grows it causes other physiological changes, swelling and may even break through into the anterior part of the eye. Until the patient comes in for treatment this condition worsens. In the best cases, treatment fully resolves the ulcer in 1-2 weeks and there is no permanent damage. In other cases, the ulcer scars and results in permanent vision loss. There are even cases where the ulcer perforates the cornea and the infection gets into the eye. This is called Enophthalmitis. This is an eye threatening disease and can result in loss the eye.

In short, limit contact lens wear to 12 hours per day, never sleep in them and replace the lens as instructed and required by the FDA. In doing so, the risks of problems are minimal. Poor compliance WILL result in pain, suffering, increased cost and possible vision and eye loss.

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Drusen are the metabolic waste products that result from increased retinal metabolism. They appear as yellow spots in the macular part of the retina. The macula is the central most part of the retina that has the highest concentration of neuro-receptors. Any alteration in this area results in decreased vision. Normal, average patients may exibit some drusen and over the course of one’s life most people will have them. The concern arises when they appear in younger individuals or in greater numbers.

The most important factor contributing to an increase in drusen is UV light from the sun. That acts as a catalyst to increase retinal metabolism and over time more drusen. Recent studies have disclosed 2 main factors that contribute to contracting macular degeneration with regard to drusen. The first is genetic predisposition. If the gene is carried and displays itself the likelihood of getting macular degeneration is very high. The severity of the condition may vary depending on other factors such as nutrition and chemical exposure. For example, if the person smokes there is 300% increase in getting macular degeneration and the severity is going to be worse. This results from vasoconstriction of the retinal blood vessels, exacerbating the already compromised vascular environment. Other drugs will have a similar affect on blood flow. Poor nutrition will also have a negative affect on the severity of the condition. On the other hand, good nutrition will increase blood flow and strengthen retinal tissue decreasing the severity of the final condition.

The second factor is the size and number of drusen. If the drusen appear as large, greater in number and more densely concentrated the likelihood of contracting macular degeneration and having it be more severe is much greater. These are factors that can not be controlled by the patient, but by wearing good quality sunglasses can at least place a major hurdle in the path of this degenerative condition.

In short, if an individual has the genetic predisposition to contract macular degeneration, UV light will results in the development of drusen. This drusen increase the likelihood of a more severe condition and thus reduced vision. The patient should always wear good quality sunglasses, avoid smoke and eat well.

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LASIK involves creating a corneal flap with either a blade or if a laser is used, Intralse and lifting the flap up. A laser is then used to reshape the underlying tissue to mold it into a better refractive surface. In doing so nearsightedness, farsightedness and astigmatism are either reduced or eliminated.

Ideally, when the corneal flap is replaced it will heal and reattach itself so there will be a smooth surface similar to presurgery. The edges of the flap must heal so that the epithelial cells (outer most layer of the cornea) heal over and stay outside of the cornea. If this occurs then the flap should remain clear and glare will be at a minimum assuming all else has healed properly as well.

Unfortunately, that is not always what happens. On occasion, some of the epithelial cells will grow around the edge of the flap and into the cornea. When this occurs the outside has joined the inside. This results in a hazy cornea and potentially dangerous condition that must be remedied. If left untreated the entire flap may become opaque resulting in devastating vision loss. Epithelial cells have different physiology then stromal and endothelial cells and must be kept out of the inside of the cornea. When this happens, the flap must be lifted up once again and the epithelial cells washed out. When done properly all the foreign cells will be gone and the problem solved.

A common complication of the procedure is that the area where the epithelial cells were may remain hazy and scar over. When this happens, that area will always be a poor refractive area and depending on the location in the cornea may cause permanent glare, haloes and vision loss. If that scared section is close to the pupillary axis, this result will be much worse then if it is farther toward the edge of the cornea. It is a one way ticket and can not be cured with additional surgery or medication. It is a possible side affect of the surgery and is not a result of surgical skill. It simply happens when the cells decide on their own to grow where they do not belong.

Careful follow up for a year is therefore suggested to monitor this potential surgical complication. The sooner it is diagnosed the better the final results should be. That and luck as to where the cells decide to grow.

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A 59 year old white male has been a patient of our office for over 10 years and has had a normal ocular history for that entire time. He does have Diabetes, but no changes in his eyes as a result of it. In the spring of 2005 he came in for his annual visit and once again had unchanged vision, and no diabetic problems. However, for the first time he did display a left lower lid lesion. This “bump” had appeared several months prior to the office visit, was painless and he would have not even mentioned it had I not asked about it.

The bump was about 2 mm in diameter, skin colored, no blood vessels growing toward it, did not bleed or have any other suspicious characteristics. Upon closer examination, I could see that it did have a noticeable blood supply and had irregular borders. While it still did not look like a big issue, its’ rapid rise, growth, and blood supply made me curious as to whether it may be the start of Basal Cell Carcinoma. Basal Cell usually appears like a small volcano with a red center and irregular sides. Most people think it is a bug bit or a pimple, and they either ignore it, or pick it until it bleeds. When the site does not heal, or gets larger patients then seek medical attention and are diagnosed with Basal Cell at that time. In this case the patient was not worried despite being informed that it may be cancer ,and thus did not follow my advice. I had referred him to an Oculo-plastic surgeon for evaluation and removal of the lesion. He never went!!

This nice man returned to my office in March of 2007 for a regular visit, and this time that lesion was 10mm in size and looked significantly different. It was much raised, had a significant amount of blood vessels growing to and into it, and appeared like a mountain range. Clearly, it now could not be mistaken for anything other then Basal Cell Carcinoma. Interestingly, the patient while noticing that the lesion was growing was not concerned despite having been told by me that it may be cancer. Even during this visit he did not want to go have it removed.

It should be noted that while Basal Cell Carcinoma is cancer it does not metastasize, that is to say it does not spread to other parts of the body. It does its’ damage by invasion of surrounding tissue. So while we see a bump on the skin level, it grows under the skin and may infect a large sub dermal area. It can, if left untreated, invade a person’s entire face. Realizing that this patient was very noncompliant, I took it upon myself to call the Oculo-plastic surgeon myself while he was in the office, and schedule an appointment for him. He was seen 2 days later and the diagnosis of Basal Cell Carcinoma was confirmed.

Surgery to remove the lesion was performed 1 week later. The part of the cancer that was on the lid was removed and complete lid reconstruction was required needing skin and tissue grafts from elsewhere in his body. The lesion had grown so much that 4 surgeries were required, and the lid will never close completely, there is decreased tear production resulting in dry eyes, but the worst part is that the cancer had invaded 35% of his face on that side. His entire left side had to be exposed and massive amounts of tissue were removed. In short, he had permanent facial disfigurement despite the reconstruction. The good news is that he is still alive.

The moral of the story is that if there is a suspicious lesion that may be cancer, have it evaluated as soon as possible and removed if needed. The longer that one waits, the worse the results will be. Basal Cell Carcinoma may not be spread via the blood, but will disfigure you if left untreated and may be fatal if untreated.

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