A clear, natural lens is a structure that is common in most eyes. This lens helps focus light on to the retina and allows for clear vision. If the lens is too strong then the eye is considered nearsighted(myopic), and conversely if it is too weak then it is considered farsighted(hyperopic). Another function of the natural lens is to absorb harmful ultra violet light that enters the eyes. This light can cause macular degeneration, and cancer in those individuals that are predisposed to those conditions. As a result of this UV light absorption, a chemical transformation occurs in the lens. The type of protein that makes up the lens, changes from an alpha type to a beta type. This alteration makes the lens appear yellow, and decreases the light transmission through the lens. This process is called cataratogenesis and results in a cataract.

When the natural lens reaches the point of cataract, that individual is unable to see clearly enough. If it interferes with daily functions, it must be removed surgically and most often is replaced with an implant. The basic concept is to improve the quality of the vision, and also reduce or eliminate the need for distance eye glasses in the process. This can be accomplished by calculating the correct implant power to focus light onto the retina. Fortunately, this is usually done when the surgery is performed by well qualified experienced surgeons.

There are factors that may complicate, and alter the final results of a lens implant. For example, in very farsighted patients the “A” factors which is critical in implant calculation may not be as accurate as would be liked, and the final implant power may significantly be off. Another issue effecting a successful lens implant, may be the implant moving forward, or back changing the effective power of the implant. In addition, if the cornea heals in such a way as to change the effective curvature, then the implant will likewise not focus light exactly on to the retina. In cases such as these, a refinement is necessary, and may consist of one of three options are available.

The first is to simply wear eye glasses. If that is not acceptable alternative, the second choice is to remove the implant and replace it. This requires an additional surgery and is most often met with patient resistance. This brings us to the third and most popular option, LASIK. LASIK is the reshaping of the cornea to focus light on to the retinal with out the need for eye glasses. A flap is created either with a microtome blade or by laser, called Intralase, and then the underlying tissue is altered with a laser. In doing so, the need for further distance correction can be reduced or eliminated. In addition, if astigmatism is only present, then circumferential incisions can be placed peripherally in the cornea perpendicular to the astigmatic power eliminating that as well.

This new procedure of post cataract refractive surgery fine tunes the surgeon’s ability to “get rid” of glasses after the surgery. Healing time is a few days, and the results are exciting. While additional surgery may not be desirable, it potentially can eliminate the need for eyeglasses or contact lenses.

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The incidence of dry eyes in America has grown dramatically over the past decade as the environment has changed, and the average age of Americans has increased. As such, new and better therapeutic alternatives are required to treat this chronic and potentially damaging condition. While most individuals simply chose to live with the discomfort of dry eyes, the physiological changes that can, and do occur as a result of decreased tear flow are worth noting.

Dry eyes can occur either as a result of decreased tear volume, or an alteration in the tear quality. There are several components to tears including water, mucin and enzymes; each with a special responsibility. If any one of these components are missing, decreased or altered the result will be dry eyes. For example, if there is an inadequate amount of mucin in the tears, the tear/cornea interface will be changed and the tears will not maintain a constant and even coverage. Tear break up time will be short, usually less the 10-15 seconds, and the eyes will become uncomfortable. Like wise if the enzyme component is altered, there is an increase in the likelihood of bacterial build up on the eyelid margins resulting in Blepharitis; which is a lid inflammation. This in turn will reduce tear production into the eye. Obviously, a simple decrease in the tear volume will result in dry eyes since there will not be enough tears to cover the cornea for the required time period.

Dry eyes result in symptoms such as sandy, burning, red eyes which if untreated will get worse over time. This will cause individuals to rub their eyes often abrading the cornea. In addition, a dry eye results in the corneal epithelium to lose its transparency giving it a milky haze. Naturally, this can and often does makes the vision worse. Continued dry eye conditions can permanently alter the corneal tissue, and scarring may result. As the eyes dry out, the lids become more involved and the Blepharitis worsens resulting in the eyes to be even dryer. It is a vicious cycle that must be broken as soon as possible.

Treatments have evolved, and patient comfort has dramatically improved along with these changes. Artificial tears are the starting point, but most often do not solve the problem. Next up is treatment with steroid eye drops along with lubricating drops. This therapy frequently does show noticeable improvement in the condition. When additional help is required, Restasis eye drops are employed to stimulate tear production. This medication is a good alternative, but does require its’ use for many months, twice per day at substantial cost to the patient. Unfortunately there are still many patients that are still uncomfortable.

The inner corners of the eye lids have small openings called Puncta. These openings drain the tears into the nose via ducts, allowing tear flow out of the eyes. On occasion, they get clogged causing tear overflow, and must be surgically opened. This concept is employed to balance tears in the eye when the eyes are dry. Small cylindrical materials can be painlessly inserted into the duct, and effectively blocks the out flow of the tears. This would be similar to covering the drain in the tub. In this case, by preventing tears from leaving the eye we can increase the tear volume, and improve comfort and function. There are two basic types of Punctal Plugs. The first is a temporary one that is made of collagen. These are great because they dissolve in 2-3 months, and result in immediate relief to the patient; but do not have long lasting potential for infection or tissue alteration. If during that 2-3 month period there is an increase in tear production then there would be no need to reinsert another plug. If additional treatments are required, it can be easily done as long as is necessary. There is also a permanent type made of silicone. These are inserted the same way, and have the exact same affect, but do not dissolve. If a problem arises they must be physically removed. In short, punctal plugs are a great way to reduce the deleterious effects of dry eyes, and significantly improve patient comfort.

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LASIK is a refractive surgical procedure that reshapes the cornea to focus light on to the retina. It is performed by creating a flap in the epithelium (outer) layer of the eye with either a lathe or laser, called Intralase. The underlying tissue is then reshaped with a laser to a predetermined arrangement in order to eliminate refractive conditions. It is designed to treat nearsightedness (Myopia), farsightedness ( Hyperopia) and astigmatism. It does not, however eliminate the need for reading glasses in those over forty. The surgery can only correct one distance at a time.

The procedure is a very effective, however there is no guarantee that there will not be any residual refractive power, or that the person my not regress requiring glasses in the future. While there are several possible deleterious side affects of the surgery, one of the most serious and potentially vision threatening is called DLK which stands for Diffuse Lamellar Keratitis. It is also know as Sand of the Sahara since it often appears like sand dunes in the Sahara desert.

This condition arises when inflammatory cells migrate into, and under the corneal flap. Depending on the location of the cells, the vision may be normal or severely reduced. Glare is often present, and in some cases the individual will present with ocular discomfort. Traditional therapy has been to prescribe strong steroid eye drops such as Pred-Forte every hour, and closely follow the patient for a reduction in these inflammatory cells. This may take days or even weeks to completely resolve. In some cases, the cells remain under the flap indefinitely.

In cases where the flap was created by a lathe, there is a gradual slope from the point of contact between the lathe and the corneal bed. This slope permitted this cell migration under the flap. It was a fairly constant degree of DLK in cases that were predisposed to acquiring this condition. Intralase, by comparison results in a step off the peripheral cornea to the corneal bed. One would think that this sharp step would reduce the number of cases and severity of DLK as compared to those with the lathe. Interestingly, DLK is more prevalent in patients who have had Intralase performed, as compared to the lathe. In either situation the cells present a problem that must be addressed.

According to Dr. Theirry Hufnagel of the Stahl Eye Center located in New York, the best treatment is to go back into surgery and lift the flap. Once the flap is once again separated from the corneal bed, the underlying area is washed and bathed with saline physically removing all the cells. This is a simple procedure, but the most effective way to completely, quickly and safely eliminate all the inflammatory cells. It also prevents any secondary complication that might arise from use of the steroid eye drops. In Dr Hufnagle’s opinion, it is the best way to remediate the DLK .

This procedure is not performed by most refractive surgeons, and only those very skilled and experienced employ it. As always, one should only have surgery with doctors who know all the techniques to deal with post surgical complications.

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Dry eyes have become a common, and potentially complicated issue facing many individuals today. The source of the problem maybe lack of tear production, Blepharitis or lid inflammation and even oil gland Dysfunction. While the treatments may vary depending on the etiology, there are some basic therapies that help all of these patients.

Chronic dry eyes can alter the integrity of the cornea, and decrease vision, resulting in constant discomfort to the patient. Effective treatment is crucial to insure good ocular health, vision and patient satisfaction. Therapies have changed over the years, starting with artificial tears and expanding to the use of anti-inflammatory agents. These new pharmaceuticals decrease swelling in the tear producing mechanism, allergies and thus increase tear volume. Additionally, the new use of Restasis (Cyclosporine) which is an anti-autoimmune medicine likewise increases tear production. Punctal plugs are frequently employed to maintain fluid volume in the cul de sac of the eye as well.

Supplements have recently been added to the therapeutic regimen in an attempt to recruit systemic assistance. For years individuals have used their own cook book method of supplements with mixed results. For the first time, a prescription supplement has been introduced that incorporates the most important components to treat dry eyes.

Tears Again Hydrate® is a new formulation that is the only prescription supplement for treating dry eyes to date. This combination contains a blend of Omega III (Flaxseed Oil), Omega VI (Primrose Oil), essential fatty acids and Bilberry Extract. These ingredients are combined with liposomes that increase absorption, and decrease digestive problems common with OTC supplements. This formulation must be closely monitored by an eye doctor to prevent detrimental drug, and physiological interactions. Hydrate treats the inflammatory component of dry eyes resulting in relief from the symptoms.

Flaxseed oil is obtained from the seeds of the flax plant, and functions by protecting the cell membranes. In addition, it also inhibits the effect of the inflammatory cascade and improves oil gland secretions; it essentially unplugs the oil gland orifices. Primrose oil is an Omega VI, and is an important component for the metabolism of Omega VI fatty acids. These are needed for healthy mucosal tissue, and good quality tear film.

Bilberry Extract is an important requirement for eye health. It is a Bioflavonoid that is water soluble, and a valuable antioxidant component for treating dry eye conditions. Hydrate also contains Safflower oil and Lecithin and Soy derivatives.

This supplement should not be taken by pregnant women or patients taking Phenothiazines, anti psychotic medications. Further, Flaxseed oil increases the frequency of defecation and should be avoided by individuals with any inflammatory bowel condition like Colitis and Crones disease.

In summary, dry eyes are a problem for many individuals, and treatments have been developed to help alleviate the nasty symptoms. Tears Again Hydrate® is the first supplement to help increase tear production, and treat the symptoms associated with this common condition.

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LASIK is a refractive surgical procedure that reduces or eliminates the need for eye glasses or contact lenses. It involves creating a flap with either a lathe or laser, called Intralase, and reshaping the underlying tissue. This new corneal curve focuses light on to the retina making it easier to see clearly. Certain conditions make having this procedure unsafe and risk severe post surgical complications. Any corneal condition that affects the water content and hydration of the cornea should be carefully evaluated prior to having LASIK. Failure to do so may result in a hazy or opaque cornea, loss of vision and the need for a corneal transplant post surgically.

On such condition is Posterior Polymorphous Dystrophy (PPMD). Most patients with PPMD never have any symptoms, and are rarely ever diagnosed with the disorder. It is an autosomal-dominant condition with no predilection for sex, race or any other societal selection. The condition does cause corneal swelling, and may also be a sign for glaucoma. This condition also results in a decreased endothelial (bottom layer of the cornea) cell count which will further increase corneal swelling. The endothelium pumps water out of the cornea, and fewer cells results in a weaker pump increasing the water in the corneal tissue.

Other conditions which contraindicate LASIK are a thin cornea usually less the 500 microns. A testing procedure known as Pachymetry must always be done to determine the exact corneal thickness. Orbscans must also always be performed to determine the difference in corneal thickness, and topography between the fronts and back corneal surfaces. Irregularities in this measurement may result in corneal ectasia, which is a warpage of the cornea causing permanent decreased vision. If hard contact lenses do not improve the vision to a satisfactory level then only a corneal transplant will improve the quality of the acuity.

Other contraindications include Fuch’s Dystrophy and Pseudophakic Bullous Keratopathy. These conditions also result in a decreased endothelial cell count. In short, any condition that results in a diminished endothelial cell measurement should eliminate LASIK as a procedure of choice. The long term likelihood of complications and corneal edema are far too great. Some of these individuals are candidates for PRK, but much care must be taken to ensure that the endothelium can still support the cornea following this surgery as well.

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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.

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