Health care has dramatically improved this past quarter century with the development of new and more effective drugs. After WW II, antibiotics were discovered and death rates declined. As bacteria have evolved; so have antibiotics. In addition, other pharmaceuticals have come along to fight viruses, most micro-organisms, allergies and even autoimmune disorders. These developments have dramatically improved the quality of our lives. Unfortunately, while there are many new and better drugs, there are still some practitioners that continue to use old, out dated, and in many cases ineffective drugs. Doctors have an obligation to change treatment modality as often as new drugs become available. What follows is a brief survey of contemporary drugs for the treatment of eye conditions. It should be understand that in 6-12 months this list will change.

A big player on this eye care stage is allergies. For many years we were stuck using cool compresses, oral antihistamines that put people to sleep and topical antihistamines. They were affective, but only treated the symptoms not the source of the problem. Today we have prescription eye drops that are antihistamines AND mast cell inhibitors. These drops treat the symptoms while decreasing the factors that cause the problem. In doing so we can rapidly improve patient comfort. The best drug is Patanol. It is a twice per day dosage medication and works with in 15 minutes of installation. In a recent development, the concentration has been increased and Pataday is now available which is the same drug that can be used ONCE per day. This increases patient compliance and keeps folks comfortable for 24 hours. None of the OTC drugs even come close to being as affective as Pataday.

Antibiotics are a big part of eye care. In the past, drugs like Bacitracin which were broad spectrum drugs were great. Today there is a 60 % resistance to it. Antibiotics need to evolve to keep up with the proliferation of resistant bacteria. We are currently on our 4th generation Fluoroquinolones. The two most prescribed are Vigamox ( 3 times per day) and Zymar ( 4 times per day). Both are presently very effective, and which ever is chosen by the eye doctor becomes a personal preference. All other topical antibiotics are a distant second in kill rates and bacterial resistance. It is important to avoid over using these drugs. Overuse can create new resistance at a fast rate, and their efficacy would be greatly reduced. .

Anti viral agents are relatively new to the field. Herpes Simplex Virus can be quite destructive to the eye, but fortunately Viroptic is available. It is quite toxic to the eye, but will kill the virus, and in most cases will save the eye from disaster. It must be used carefully and followed very closely. A newer anti viral is Valtrex which is commonly used to treat Herpes. It can be used as a long term therapy while Viroptic is strictly short term.

Anti inflammatories have changed quite a bit over time. In the past, steroids were the only game in town. They are still used, and are among the most effective drugs, but they do come with potential side effects. They can cause cataracts, glaucoma, reduce healing rates and will increase blood glucose levels. Careful follow-up is essential when undergoing steroid therapy. Pred Forte is still the gold standard for serious inflammations. Dexamethosone usually in combination with Tobramycin in a formulation called Tobradex is one of the most widely prescribed medicines. Soft steroids have recently made their entrance on to the market in the form of Lotemax. Soft steroids have adequate anti inflammatory properties with out the side affects of regular steroids. They are however, not as affective in serious swelling conditions.

New developments in inflammation is the advent of Non Steroidal Anti Inflammatory agents like Acular, Voltarin and now Xibrom. They are effective, bring new treatment options to the table and can be used long term. Xibromis often used post surgically, but retards healing. They also can be used topically to reduce some retinal swelling like Central Serous Retinopathy.

An old drug that has found a new use is Cyclosporin. It is an anti autoimmune drug that had seen a decreasing use. It has been found to increase tear production in the lacrimal gland by reducing swelling. In doing so, tear production increases after about 2-3 months of use. The new/old drug is called Restasis, Care must be exercised when using Restasis; it must be discontinued if an infection exists. Continued use will result in a major infection that.

These are the newest and best ocular drugs available today. While older medications have some value, it is essential that contemporary therapy be instituted. This will protect the patient, and control the proliferation of organism mutations.

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There are many herbal, nutritional, alternative and vitamin supplements that have been suggested to improve eye sight, and prevent ocular disease. While some have positive effects on the visual system, there are others that can become toxic and have a destructive influence on the eyes. It is generally believed that a well balanced “American” diet does not require supplements, and their true value is negligible. While many have some benefit, care must be taken since supplements can interact negatively with other medications and even foods that are ingested. For example, milk negates the positive antioxidant affects of tea, and citrus increases the pharmaceutical benefit of cholesterol lowering medications.

Studies recently performed have concluded that most of the evidence points to a stronger prophylactic effect of these supplements rather then a therapeutic one. Specifically, with regard to Age Related Macular Degeneration, Vitamin E, and antioxidants appear to be significant factors that effect the onset and severity of the condition. Some observational studies have concluded that higher ingestion of antioxidants result in lower incidents of AMD. Additionally, the intake of Zinc has long been thought of, and has now been proven to reduce the likelihood of pigmentary anomalies often associated with Drusen, a risk factor for AMD. Those who took Vitamin E in the Beaver Dam study had a 13% lower risk of displaying AMD. It appears in most studies that the nutritional benefit is in prevention of vision loss in those who had a moderate to sever risk of AMD. It further appeared that the antioxidant had the greatest affect in this prophylaxis, or prevention, and that Zinc worked only in combination with the antioxidant, but not so much by itself.

The Age Related Eye Disease Study ( AREDS) found that the best combination to prevent vision loss was with the combination of Vitamins C,E, Beta Carotene, Zinc and a small amount of Copper. It should be noted that while these supplements did help prevent the visual loss, it also increased the risk of lung cancer in smokers that were predisposed to that disease.

Other supplements that were found to be helpful were Carotenoids such as Lutein which helps filter blue light out of the macular. Zeaxanthin also helps filter out the high energy blue light from the central retina. Beta Carotene is important in the production of rods and tear formation, while Amino Acids like Glutathione protect against toxicity. Another supplement is the herb Gingko Biloba which increase blood flow to the retinal tissue in proper amounts.

With regard to cataracts, Lycopene commonly found in tomatoes, and tomato products, reduces the transformation of the Alpha protein to the Beta protein resulting in cataract formation.

Neurologically, B complex vitamins like B6, B 12, Niacin and folic acid are extremely beneficial. With regard to Dry Eye Syndrome, Omega III fatty acids have been shown to increase tear production after approximately 2-3 months of intake. Also, Potassium ( K) found in bananas, improves tear film osmolarity, resulting in a more stable tear film.

In spite of their positive effects, nutritional supplements can be detrimental, there can be adverse reactions to these super supplements. St John’s Wart often used to combat depression can cause photo toxicity and toxic affects in the retina. It can also result in cataract formation if taken for about 5 years. Ginkgo Biloba which is used to increase blood flow, can also cause vein inflammation. This can be a big problem with those taking Viagra or who have vascular disease. Garlic, a favorite of the Transylvania crowd reduces blood pressure and keeps strange people and vampires away, but at the expense of blocking platelet activity. This may result in excessive bleeding, and spontaneous hemorrhaging.

In short, supplements do have a place in maintaining proper health, and disease prevention, but caution must be exercised. It would be wise to discuss any supplements you take with your doctor, so that undesirable interactions can be avoided. Nutritional supplements can certainly help, but they are no substitute for proper, balanced eating, getting 6-8 hours of sleep, regular exercise, and stress reduction. They should be considered as an adjunct, rather than a replacement therapy for healthy living.

Nutritional Supplements vitamin ocular disease cholesterol antioxidant Age Related Macular Degeneration Vitamin E Zinc Drusen AREDS Beta Carotene Copper Carotenoids Lutein Zeaxanthin Glutathione Gingko Biloba Lycopene cataract B complex Dry Eye Syndrome Omega III fatty acids St John’s Wart retina

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Health care has been much improved since the discovery of antibiotics. Prior to WWII, Sulfa drugs were the treatment of choice to fight bacteria and were quite successful, but did not cover all the organisms that attacked humans. As a result, many perished and even more suffered debilitating diseases. Antibiotics were the answer to fighting infections.

As time went on, improved antibiotics were developed, increasing the range of bacteria killing rates. They work in one of two ways. The first, is Bacteriostatic. This inhibits the bacterias ability to reproduce. In doing so, they die off since they can not sustain their populations. The second, is Bactericidal. This method directly kills the bacteria in ways ranging from destroying the cell wall to disrupting their metabolism. Choosing the correct antibiotic depends on which bacteria is involved, the age and type of patient and level of toxicity permitted.

Evolution is a fact of life, and dealing with bacteria is no exception. As antibiotics have been used, the bacteria have become resistant to them through evolution. Thus, new and better ones needed to be developed. We are currently on the fourth generation Fluoroquinolones as the most advanced level of antibiotics. The average effective life of an antibiotic has been reduced to only several years before a large percentage of bacteria become resistant to them. This is due in part to the over use by doctors of the medications. A sad but true fact.

We are now facing a true demon, and deadly organism in the MRSA or Methicillin Resistant Staph Aureus bacteria. It has been publicized in the news because it is an antibiotic resistant bacteria that has a VERY high fatality rate once involved in the blood stream. The usual case scenario is that a patient goes to the doctor with an infection and is treated with standard antibiotics. They return to the doctor in a few days after getting worse, and then are treated with stronger ones. Unfortunately, once the infection gets into the blood, it is often too late. If it is a skin infection, the affected area can be surgically removed, but if is has spread, the results are all too often deadly.

The best treatment for MRSA is Vancomycin. So the logical question is why not treat all patients with it. The answer is that it is a very strong antibiotics, and is very toxic. If it is not MRSA then the patient may become resistant to it and if then needed, it will not work. Plus it is toxic and should only be used when needed. A current problem is that is has been over used, and there are MRSA bacteria that have already become resistant to it. That means that if needed, it will not work, and may result in death to the patient.

In short, if you have an infection, see your doctor as soon as possible and be aware that if you do not get better in a few days return to him/her because you may have MRSA and may need a new treatment. Failing to do so, may be fatal.

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Nystagmus is the involuntary lateral movement back and forth of the eyes. It may be so mild that it goes unnoticed or it may be quite severe and substantially reduce ones’ vision. It would be like shaking a camera back and forth, and creating a very blurry photograph.

Involuntary eye movements originate in the brain stem, at the base of the skull, and are part of the autonomic nervous system. That is also the part of the brain that controls things such as heart beat, breathing and all systems that are centrally and involuntarily regulated. Most nystagmus are a result of congenital anomalies, but on occasion they may result from trauma and pharmaceuticals.

Many people are aware that when cars are stopped at police road blocks for sobriety checks, one of the steps taken by the officers is to see if a driver has nystagmus. So the question that begs to be answered is why? The answer is simple. Alcohol is a drug that directly affects the central nervous system. These affects cause many folks to lose balance, speech coherency, and some vision. These affects on the brain stem have been well documented. People who are predisposed to nystagmus, will ultimately develop nystagmus when their alcohol level exceeds a certain level. When a police officer checks a possible drunken driver and finds nystagmus, that driver will be in deep trouble! The onset of nystagmus is a clear indication of alcohol intoxication.

The next obvious question is what if the person always has nystagmus? In that case the person will have to prove that he suffers from that condition, and note from an eye care practitioner will do. The actual number of people that suffer from nystagmus is quite small, which makes it a very good tool to be used by the police. The problem with the nystagmus test is that there are a large variety of other reasons that can result in a person displaying nystagmus.

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Keratoconus is a genetic, recessive condition that affects less then 1% of the population, is progressive and can have devastating affects on the vision. There are several types of the condition each demonstrating varying degrees of severity.

The mild variation of the condition will present with decreased vision that is most often treated with eye glasses. The vision is corrected to 20/20 and frequently no diagnosis is even made.

When the vision continues to get worse, additional testing must be done to determine the etiology of the changes. A corneal topography must be performed to make the ultimate differential diagnosis. The inferior nasal area of the cornea is steeper then the rest of the cornea and is the only possible diagnosis. When this occurs careful examinations must be performed in order to maximize the visual acuity. When acceptable vision is not achieved with eye glasses, then Gas Permeable contact lenses must be employed. These lenses mask the irregularities of the cornea and give the best visual results.

As the condition continues to progress the central cornea near the cone will get thinner and protrude anteriorly. Danger exists when the apex of the cone touches the posterior surface of the contact lens. This interface can result in scarring of the cornea and permanent decreased vision. Careful and frequent evaluations must be performed to continuously redesign the lens to vault over the cone. On occasion, if an acceptable fit can not be achieved then a “piggy back” method must be used. This involves fitting a soft contact lens under the gas permeable one. The soft lens acts as a cushion and protects the cornea while still maintaining good comfort and vision.

I recently had a patient whose corneas had progressed to the level that even the piggy back was not giving the patient enough comfort so I had to refit the worse eye with a custom made soft contact lens specifically designed for Keratoconus. This increased the comfort and prevented the eye from getting an apical scar from the lens. The best vision in that eye was not as good as possible, but in combination with the other eye which still had a gas permeable lens, the vision was adequate.

If the condition progresses to the level that no improvement can be achieved with lenses, then a corneal graft must be performed. That topic will be discussed in another article.

In short, if a patient has declining vision that appears to be irregular in nature, Keratoconus must be considered and special contact lenses employed.

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