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.

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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.

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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.

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Cataract surgery has been performed for many years, and new developments have dramatically improved the post-op vision. The lens is a normal structure of the internal part of the eye. We are all born with clear, natural lenses whose function is to focus light onto the retina, and also absorb dangerous wavelengths of light. Over time, this clear lens will become yellow, as its chemical structure changes as a result of years of light absorption, and general oxidative stress on the body.

Early cataract surgery involved simply removing the cloudy lens from the eye. In order to see, the patient then had to wear very thick eye glasses, or a contact lens. As technology advanced, anterior chamber Intraocular lenses(IOL) were developed. These were artificial lenses that were placed in front of the iris to replace the removed lens. They worked very well, but over time the corneas were damaged in most of these patients. These anterior chamber lenses vibrated as a result of aqueous humor (fluid) flow from the back of the eye toward the front. These vibrations over time damaged the endothelial (bottom) layer of the cornea resulting in swollen corneas, and cloudy vision.

The next big change was the development of posterior chamber IOLs. These are placed behind the iris, and thus eliminated the vibrations; sparing the cornea from trauma. Over time, improvements were made to these lenses; smaller, better quality and flexible so they could be implanted with very small suture-less incisions. The basic problem with all of these implants was that unlike the natural lenses of the eye, only distance correction could be achieved. Reading glasses were necessary to see objects up close. This brings us to the next big change in the IOL implants. In an effort to meet the challenges of allowing patients to see distance and near post surgically, multi-focal implants have been developed.

The major new players in this game of multi-focal IOLs include Restore by Alcon, Rezoom by AMO, Array and Tecnis also by AMO and Crystalens by Eyeonics. They are all designed to give the patients a full range of vision from distance to near without the need for any eyeglasses. Each type achieves this goal through different modalities.

The Restore implant is manufactured with multiple small concentric rings, similar to the rings of a dart board. These concentric rings alternate between distance and near vision. Multiple images are projected onto the retina, and the brain must then decide which image it wants to see clearly. Most patients say that they see adequately in the distance, and usually test to about 20/40 vision. Near vision is a bit better in most patients. The primary complaint, aside from less then perfect distance vision is glare at night. Approximately 80% of these patients do not wear any type of glasses post surgically.

The Rezoom lens works in the same manner as the Restore, but has larger concentric rings. This improves the distance vision, but reduces the near vision. 81% of these patients are happy with their reading vision, but 29% still require reading glasses to see at near. With both the Restore and Rezoom implants, Alphagan eye drops are employed to reduce bothersome glare by reducing the pupil size.
The Tecnis IOL is not as yet available, but since it is made as an Aspheric lens and not concentric rings, there is less glare and halos and better reading in dim light. It also permits reading with a greater range. More research will bring to light the true value, and short comings of this implant.

The Crystalens is the first IOL that has an adjustable focusing ability, much like the natural lens of the eye. The implant is placed behind the iris, and has 2 flexible hinges 180 degrees apart from each other. As the ciliary muscle contracts, and relaxes it causes the implant to move forward and back changing the effective power of the lens. This mimics the natural lens’s power change with focusing. It is therefore the first and only Accommodating implant that allows for bothe near and far vision. Substantial adaptation is required, and may take weeks to even months to reach an acceptable level of vision. There is, however a decrease in contract sensitivity ,and some distortion may be induced. Reading glasses may be required for the intermediate distances, and in patients with larger pupils night time vision issues may be present.

Which implant would be best for any given patient will vary, and depend on factors such as expectations, side effects, need for bilateral surgeries (since some implants work best when each eye has one) and cost. Insurance plans do not pay for these specialty implants, and the combined costs with the doctor’s fees may be over $2000.00 per eye.

Finally, some patients have astigmatism following cataract surgery. Since the implants do not correct for this, corneal incisions can be made post surgically to reduce or eliminate that component.. When deciding to have cataract surgery it is important to see an experienced surgeon who is knowledgeable with all these new developments, and can best asses which implant would be best for which patient.

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