The natural lens in our eyes should be perfectly clear when we are born. There are exceptions such as congenital cataracts, certain opacities caused by drugs, trauma and unusual changes that happen idiopathically. However, most people are born with clear lenses. This lens has two main functions. The first is to focus light onto the retina. The second is to filter out Ultraviolet light from reaching the inner parts if the eye. As time passes the lens will become yellow as it absorbs the high energy light. This change is called cataractogenesis which is the making of a cataract. When the lens becomes so hazy that one’s vision is reduced then surgery is required in order to improve the visual acuity.

The procedure will remove the altered natural lens and replace it with a synthetic Intraocular Implant. This is a permanent correction that will dramatically improve the patient’s vision. The implant is placed behind the iris in the eye and is held in place by the posterior surface of the original lens. In approximately 50% of the cases this membrane will become hazy and make it appear that the lens and cataract have grown back. The vision will become hazy, blurry and there may even be some double vision. This is often referred to as a “secondary cataract”. Fortunately, the treatment is very easy and highly effective.

In order to improve the vision a Yag laser is employed to make a hole in this membrane and eliminate the haziness. The procedure takes a few seconds and permanently solves the problem. In order to have this therapy the patient must wait until after the post op period which is 45 days after the surgery.

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Contact lenses have been around for more then half a century. They started as glass lenses, and evolved into many different types of soft plastic polymers. These changes have been dramatic, and have enabled millions of people to wear contact lenses comfortably for a whole host of activities. The biggest hurdle to overcome had been correcting near and distance vision in the same lens. This was accomplished with a certain degree of success with several lenses, but most still lacked complete visual correction. In most of the lenses there always remained some uncorrected astigmatism which ultimately reduced one’s best visual acuity.

The first big step forward came with the development of the Gas Permeable Joe Focal by International Contact Lenses in New York City, but as with all Gas Permeable lenses comfort was an issue. The next very successful lens was the Ultravue Multifocal which while it had limited parameters was able satisfy many patients. That came to an end when the company was sold to Coopervision, and was subsequently discontinued. It was a good, and I fail to understand the logic of its discontinuance. Coopervision attempted to replace the Ultravue with their Proclear Multifocal and Frequency 55 Multifocal, both of which do not even come clear to that goal. Neither lens has the ability for full astigmatic correction; they have limited parameters in base and combination of powers. Not a good move.

Moving ahead, a recent entrance into the contact lens arena has revolutionized the industry. The Synergeyes Hybrid Multifocal has answered the cry for help in an outstanding fashion. It improved on an older lens called the Softperm. The central part of the lens is gas permeable, which is surrounded by a soft lens skirt. It gives the 100% visual acuity of a rigid lens and the comfort of a soft lens. It corrects 100% of the astigmatism, near and farsightedness, and is a multifocal lens permitting the individual to see at near and far with out any eye glasses or sacrifices. We have fit many patients in this great new lens, and have had incredible. The comfort is great and the vision outstanding.

Most practioners may not be well versed in this new development, but once it catches on, other lenses better make reservations at the retirement home because this lens is the real deal.

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The pursuit of good vision through various methods has been going on for centuries. When Ben Franklin invented bifocal eye glasses, it revolutionized vision care forever. As time progressed, contact lenses were invented and gave people another alternative to vision correction. Original contacts were actually made of glass, and have evolved to many new and better polymers. In an effort to improve comfort, ocular health, and vision new materials are being invented on a regular basis, and have proven to dramatically help the contact lens industry.

Patients requiring vision correction demanded an alternative to eye glasses and contact lenses, and thus refractive surgery entered the arena. It started with Radial Keratotomy and evolved to PRK and LASIK which are fairly common procedures world wide as this date. The question then is which is better to improve one’s vision; contact lenses or LASIK? To answer this question one must examine the pros and cons of each, and then decide which alternative would best suit their needs.

Contact lenses are tried, and true and a known entity. The choice of materials and visual options is great and in most cases, in the hands of a skilled and experienced contact lens doctor, most patients will see well and have all their visual needs met. This includes nearsighted, farsighted and astigmatic patients, and the individual that needs reading glasses because of age or a focusing spasm. Today there are multifocal contact lenses that correct both eyes in the distance, near and intermediate distances with seamless visual comfort. These lenses are available in disposable, non disposable, gas permeable and even hybrid lenses. They possess all the characteristics required to permit clear comfortable vision at all distances with out any sacrifices of vision and binocularity.

Contact lenses do require maintenance and common sense. That is where they fall short in the public eye. The first consideration is minimal since most patients use a single step multi purpose solution that simply requires an individual to rinse and store the lenses daily in a case. Unfortunately, there are compliance issues when a patient does not rinse the lenses, change the solution or even clean the case. They blame the procedure as the reason for not doing it properly, but it is a simple as it gets. Some folks complain that they are tired of having to put the lenses in and the cost of the lenses as well and not being able to see with out them. Nevertheless, being dependent on contact lenses is an understandable reason to seek an alternative.

LASIK and PRK are surgical procedures that reduce, or eliminate the need for eye glasses and contact lenses. For the individuals that want to see without any visual aid, these procedures are the answer. The positives are that they are good, effective therapies and most often will eliminate the use of the glasses. However, there are several issues that must be taken in to consideration. The first is that there are no guarantees that there will be no visual correction after the surgery. A small prescription may be needed for distance or computer use, and there may be some regression. In addition, the eyes tend to become dry and glare and haloes are usually present at night. Most of these symptoms do resolve over time, but can be disturbing until they do. Furthermore, the procedures can correct the vision at one distance only. That means if a patient has the need for distance and near eye glasses they will either have to have both eyes corrected for the distance and then wear reading glasses or correct one eye for the distance and the other for near. This technique is called monovision, and not all patients are happy seeing distance with one eye and near with the other. They lose depth perception and often complain about poor night vision.

In short, both visual aids like contacts and glasses and refractive surgery are acceptable alternatives to vision correction. Which alternative is chosen is a personal choice and careful thought must be taken before undergoing a surgical procedure. Patients can always take off the contact lenses, but can not undo the surgery.

If you are thinking about purchasing contact lenses online, Lens Shopper is a portal that allows patients to comparison shop for their contact lenses.

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The lid is a very complex, and important structure. It has multiple functions that require a constant flow of fluids, and physiological maintenance. Disruption of any part of this mechanism can, and often does result in disease, pain and the possibility of secondary complications. The lid’s most basic function is to protect the eye from trauma. This is accomplished by simply closing the eye. The lashes also play a role as they catch debris, and inform us when something is too close to our eyes. In addition, they house many glands that secrete fluids that bathe our eyes and keep them moist.

If any of the glands of the lid get clogged, infection results, and often called a stye. It present as a red bump in the lid, that is tender to the touch. The lid is red and swollen, and may even appear as a pimple on the lid if the infection is in the front section of the lid. Another lid infection, blepharitis, is an inflammation of the lid, and appears as a red lid margin with debris on the lid surface. It often leads to dry, red eyes, and general discomfort of the eye. Proper treatment will alleviate this condition.

A more serious condition of the lid area is Dacryocystitis which is an infection of the nasolacrimal sac. This lies between the inner corner of the eye lid and the nose. It most often results from blockage of the duct that permits tears to flow from the tear producing gland to the nose. This condition most often causes pain, redness and swelling of the inner most area of the lid, and excessive tearing. The blocked tear duct becomes infected with bacteria such as Staphylococcus aureus, Streptococcus pneumoriae and Pseudomonas. Dacryocystitis may be acute or chronic and may be the result of tear duct malformation, injury, trauma and infection.

Clinical presentations will include the pain, redness and swelling as well as puss that will extrude with digital pressure to the area. Most patients are very uncomfortable and present with a puffy red inner eye lid. It looks different then a basic lid infection in that the location, and is always nasal and the pain is much more severe with palpation, or digital pressure.

According to Dr. Marc Werner, an Oculoplastic surgeon from Long Island, NY, aggressive treatment is necessary to prevent secondary complications. He recommends irrigating the infected duct to clear any obstructions, and clear away bacteria infected puss. If the irrigation is not effective in opening a clean duct, then surgery is required to cure this condition. In addition, oral antibiotics, and topical antibiotics and on occasion a topical steroid is employed to reduce the inflammation. Palpitating the effected area to remove as much of the puss as possible is necessary at the onset of treatment. Proper follow up is also required on a daily basis to make sure that the infection is draining and not spreading to the surrounding ocular areas. Dr. Werner always checks vision and pupillary function on every visit for the same reason. It should be noted that Dr. Werner is also a Neuro-Ophthalmologist and as such always looks for any potential neurological complication that might arise.

If the Dacryocystitis does not resolve with this therapy, and the duct remains obstructed then when the initial infection is eliminated a surgical procedure called Dacryocystorhinostomy ( DCR) must be performed. This is done under general anesthesia and creates a new passage for the tears to flow. As usual, proper diagnosis and treatment is required from the start to obtain the best possible outcome.

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Radial Keratotomy (RK) has been referred to by some as the “Grand Father” of Refractive Surgery. It involved making radial incisions in the cornea some times as deep as 80% of the total corneal thickness in an attempt to flatten the tissue. Astigmatism was treated with specific incisions located in strategic parts of the cornea. The astigmatic incisions were done first, since they created more nearsightedness and when they healed, the radial ones were performed. The optical zone around the pupil varied depending on the degree of nearsightedness that needed to be corrected.

Having seen many thousands of patients that underwent this procedure, I can say with confidence that most complained of glare and the vast majority regressed and required eye glasses not long after the surgery. That period varied from several months to many years. The “father of RK” was Dr. Fyedorov who did his research, and refined his technique on thousands of “very willing” citizens of the Soviet Union. During that time in the 70′s and 80′s his reported results were outstanding. To date it is very hard to find any negative results or complaints from his work. Evidently the Soviet Union may have had a hand in his clinical data reported for public consumption.

RK was brought to the United States by 5 American eye surgeons, two of the most well known being Dr Norman Stahl and Dr Jerry Zelman. They both travelled to Moscow to study with Dr Fyedorov, and I even had the pleasure of being in the office with Dr Stahl when Dr Fyedorov visited him in his Garden City, Long Island office. Dr Stahl was an outstanding doctor and surgeon, and personally performed many thousands of RK procedures. In the short term, most patients were happy with the results. However, where are these patients today? How do they see and what do their corneas look like so many years after having surgery?

I have had the pleasure of examining a number of these same patients years after their procedure. Most, if not all of these folks that I examine require an eyeglass prescription. Most are farsighted, and have a significant degree of astigmatism as well. Their prescriptions are generally unusual, and have acquired unconventional astigmatism. Another very common finding is the presence of a brown semicircular ring in the inferior half of the cornea. The inner most layer of the cornea is a single layer thick, and when RK was performed that layer was stretched thin as required to cover a larger area. Its function is to pump fluid out of the cornea, and keep it at the proper hydration level. However, as this thin layer was stretched out its function was negatively affected. As a result, it left the heaviest materials behind; Iron. Therefore, this brown deposit is iron left in the cornea by a weakened endothelium layer. It does not appear to have any visual effect, or create any physiological determent, but is a constant. What the future holds for these patients is still a question mark.

The big question is why all these patients are farsighted, and what can be done about it. The answer to the first question is still a mystery. It is possible that they were deliberately over corrected to compensate for the regression or more likely, the corneas were so weakened by the RK that they became flatter over time, and warped causing the astigmatism. Unfortunately, both Drs Stahl and Zelman have passed away and are not available for consultation regarding this matter. A weakened cornea is free to change with out any guidance, since both internal and external pressures can reshape it. The one constant is that they all need some refractive help. In fairness to all the RK surgeons, today’s technology was not available to them. There were no topographers, no Orbscans, and many other measuring instruments that we routinely use today. In addition, surgical calculations were made on a regular refraction. The FDA and all the surgeons did not require cycloplegic refractions which eliminate any spasms of the focusing system abnormalities from impacting the presurgical calculations.

Many of these patients are having PRK as a way of correcting their vision and improving their distorted vision. At least today’s technology has corrected the errors of the past. One must question if 20 years from now we will be having the issues about LASIK or PRK.

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Diabetes is a systemic disease that can, and often affects many areas of the body. The search for a cure has been long, and difficult, and to date the only therapy has been to manage the condition and treat the symptoms. While better blood glucose control has been at the apex of this therapy, it has not stemmed the secondary changes that damage collateral bodily systems. An often devastating diabetic complication is bleeding in the back of the eye, or retina. This condition is called Diabetic Retinopathy. There are several stages of this condition starting with simple dot and blot hemorrhages. This is when the blood vessels in the eye leak blood. As this continues to worsen, the bleeding gets more extensive and blood components are seen in the retina as well. This condition is called Preproliferative Diabetic Retinopathy. This stage is usually accompanied by other systemic problems concomitantly.

As the retinal condition deteriorates, the patient enters the proliferative stage (PDR) where extensive bleeding, inflammatory fluids and some retinal tissue death occur. Until recently. improved blood sugar management was always advised and retinal laser therapy was employed. It basically treated the symptoms, but not the condition. While these therapeutic approaches are still used, new potential therapy has emerged that may be far superior in preventing these devastating ocular complications.

A study recently published in the Archives of Ophthalmology described research involving Avandia which is a diabetes medication. It concluded that this drug may delay, or prevent the onset of proliferative diabetic retinopathy. This medication is an anti-angiogenic drug that slowed new vessel growth in the retina caused by the retinopathy. New vessel growth in the retina typically causes lose of vision in that area. By preventing this new, immature and unwanted blood vessel growth, the proliferative changes can be avoided and the potentially sight threatening condition may be avoided.

The three year follow up of this study demonstrated that 19.2% of the individuals progressed to progressive diabetic retinopathy, while 47.4% did not. The study further concluded that using Avandia reduced the relative risk of contracting PDR by 59.5%. While these results are very exciting, and promising to diabetics, there are other factors that may contribute to success or failure of this drug as it applies to the retinal condition. Other medical conditions, stability of the blood glucose level and insulin use are but a few of these external factors.

Further studies must be conducted before this drug can be used as a standard for diabetic retinopathy therapy, but at the very least a great starting point.

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