Dr. Steven Suh has a new podcast called Healthy Eyes 101. This is a patient-centered health education program focused on the eyes. He will be interviewing ophthalmologists and optometrists to discuss various eye conditions and their latest treatments. If you would like to see Dr. Suh’s Healthy Eyes 101 podcast website, please click on the logo.
Billions of people around the world can see more clearly because of eyeglasses. To help us learn about glasses and the latest in lens technology, Dr. Suh interviews Kara Jones, a licensed optician with Comprehensive EyeCare.
We discuss the importance of the measurements performed on your eyes. The various types of lenses can be confusing – single vision, bifocals, trifocals, progressive, no-line bifocals, etc. Lens materials are improving and are enabling people who have higher prescriptions to wear thinner lenses. Digital lenses are all the rage in the optical world and allow people to see clearer than before. We also discuss polarized lenses in sunglasses, blue-filtering lenses, Transition lenses, and anti-glare coatings. Many people who purchase their glasses online can end up with buyer’s remorse. Find out the advantages of ordering your glasses from an optical shop.
For more information about choosing the right frames and lens materials, please go to this website from the American Academy of Ophthalmology.
Side effects from medications are common. What may not be common knowledge is that there are systemic medications that can affect the eyes. For example, anti-hypertensive medications and some psychiatric medications are known to exacerbate dry eyes. Some oral medications can also adversely affect the retina, the delicate tissue inside the eye that receives the visual information.
One of the most commonly used medications that can affect the retina is hydroxychloroquine (Plaquenil), a medication used to treat rheumatoid arthritis and systemic lupus erythematosus. Its cousin, chloroquine, an anti-malarial medication, can also have the same effect on the retina. Use of hydroxychloroquine after years may cause accumulation of the medication in the RPE (retinal pigment epithelium), the layer underneath the retina. It is most likely to accumulate in the macula, the part of the retina that is responsible for central vision. Thus, this can cause significant loss of distance and reading vision.
Risk factors for retinal toxicity from hydroxychloroquine or chloroquine
- Daily dosage greater than 400 mg per day or total cumulative dosage of over 1,000 grams.
- Medication use for over 5 years
- Kidney or liver disease
- History of macular disease such as macular degeneration
- Age greater than 60 years
Patients who take these medications should have an annual eye examination that may include OCT (ocular coherence tomography), visual field testing, color vision testing, and possibly an ERG (electroretinogram). Many times, early changes can be detected by the examination and ancillary testing even before the patient has symptoms. There is no treatment for this other than to stop the medication immediately. The blind spots that can occur are usually irreversible.
Pentosan polysulfate (Elmiron) is a medication used for interstitial cystitis, a condition that can cause bladder pressure and pain. This drug can also affect the central macula and mimic macular degeneration. The risk factors for these changes are similar to hydroxychloroquine. There is no treatment other than to stop taking the medication.
Here are some links to learn more about how these medications can affect the retina.
Angle-closure, or narrow-angle, glaucoma is the other major type of glaucoma that can afflict patients. Fluid inside of the eye drains in the trabecular meshwork, the space between the cornea and the iris. When this space, or angle, narrows down, the trabecular meshwork can get blocked, which can cause the eye pressure to rise and increase the risk of glaucoma. In this episode, Dr. Wendy Kirkland explains all aspects of angle-closure glaucoma.
There are several categories for this type of angle configuration in the eye.
- Primary angle-closure suspect
- Primary angle-closure
- Primary angle-closure glaucoma
- Acute angle-closure crisis
The risk factors for angle-closure include
- Asian descent
- Hyperopia (farsightedness)
- Older age
- Female gender
- Short axial length (length of the eyeball)
- The size, shape, or position of the crystalline lens
Like primary open-angle glaucoma, many patients with angle-closure have no symptoms so this is why it is important to have your eyes examined on a regular basis. The eye doctor can perform a gonioscopy exam to diagnose whether you need to have treatment to correct this condition.
The signs and symptoms of an acute angle-closure crisis or attack include blurred vision, slightly dilated pupil, a red eye, extreme eye pain, headache, and nausea and vomiting.
Plateau iris and secondary causes of angle-closure need to be ruled out to administer the proper treatment.
Treatments include a YAG laser peripheral iridotomy or cataract surgery.
Here is another site where you can learn more about narrow-angle glaucoma.
Ophthalmic, or visual, migraines are a common reason for urgent visits to the eye doctor. In this episode, Dr. Suh interviews Dr. Vin Hoye, a neuro-ophthalmologist, about this condition. He will discuss the various images that people can see when they are experiencing the migraine aura, which may or may not be followed by the classic headache. There are certain foods and risk factors that may trigger migraines. We will discuss the other diagnoses that may mimic ophthalmic migraines and whether or not there are treatments for the visual symptoms.
Here are some extra links about ophthalmic migraines.
The treatment of glaucoma, one of the leading causes of blindness in the world, involves lowering the eye pressure. In previous episodes, we discussed glaucoma medications and minimally invasive glaucoma surgeries, or MIGS. Dr. Megan Chambers, a glaucoma specialist from Ophthalmic Surgeons & Consultants of Ohio, will be discussing the use of lasers and more traditional surgeries to help lower eye pressure in the quest to halt the progression of glaucoma.
Selective laser trabeculoplasty (SLT) has gained in popularity over argon laser trabeculoplasty (ALT). SLT applies laser energy to create changes in the trabecular meshwork (drainage tissue) to allow fluid to filter out easier. This relatively quick, in-office procedure may take up to 3 months for the pressure-lowering effect to occur. It has about an 80% success rate and can be used as a first-line treatment or as a replacement for glaucoma eye drops.
Trabeculectomy is a surgical procedure performed in the operating room that is designed to lower intraocular pressure when medications and laser have failed to lower the pressure enough. A small flap is made in the eye wall near the cornea, and a small hole is made underneath this flap to let the eye fluid filter out slowly. The conjunctival tissue above the flap forms a “blister” called a bleb. Many times, patients will be able to stop their glaucoma drops after a trabeculectomy.
Glaucoma drainage implants, or tube shunts, are devices that are placed underneath the conjunctiva. The tube is placed into the eye and drains fluid into the plate portion of the implant. Usually this procedure is done after a trabeculectomy has failed.
Preserflo, formerly known as InnFocus microshunt, is undergoing FDA trials as a possible alternative to these traditional surgeries but with fewer side effects and complications.
Here is another great resource on glaucoma treatments.
On this special 20th episode, Dr. Suh talks with Dr. Jim Caudill, an ophthalmologist from Charleston, West Virginia, about their work with Medical Ministry International (MMI), a Christian medical mission group whose volunteers participate in one- and two-week projects to developing nations.
Several of the leading causes of visual impairment in the world are preventable or treatable. People with uncorrected refractive errors, which means they are nearsighted, farsighted, and/or have astigmatism, can see better with a pair of prescription glasses. But in many developing countries, prescription glasses are not easy to obtain. Cataract, a clouding of the natural lens, is responsible for about half of the world blindness, which represents about 20 million people. Lack of access to or lack of financial means for surgery as well as longer life expectancy are some of the factors that have led to this increasing number of untreated cataracts.
In the developing world, being blind decreases one’s life expectancy by one-third. 50% report loss of social standing and decision-making authority. Children may be unable to attend school because they must care for their blind relatives. The annual worldwide productivity cost of blindness is estimated to be in the hundreds of billions of dollars.
Many charitable medical organizations have been around for decades to do short-term trips in these developing countries to lessen the burden of their much-needed medical care. MMI has been around for over 50 years. They provide dental, medical, surgical, OB/GYN, eye care, and physical therapy services around the world with short-term missions and in their permanent centers.
For more information about Medical Ministry International, click here.
Diabetes mellitus can affect the eyes in multiple ways. Even early in the diagnosis, high blood sugar levels can cause changes in the natural lens of the eye that can alter one’s refractive error (glasses prescription). Diabetes can also lead to earlier cataract formation. On this episode of the Healthy Eyes 101 podcast, Dr. Lisa Borkowski, a specialist with Midwest Retina, talks about diabetic retinopathy, one of the leading causes of vision loss in the United States and worldwide.
Symptoms of diabetic retinopathy (DR) include blurred/distorted vision, an increase in floaters, or dark areas in the field of vision. However, many patients do not have any visual symptoms at all. This is why diabetics should have their eyes checked on a regular basis. Those with type I diabetes should get their first exam within 5 years of diagnosis. Those with type II diabetes should be examined soon after diagnosis because many of these patients may have had uncontrolled sugar levels for years.
The two main categories of diabetic retinopathy are non-proliferative (NPDR) and proliferative (PDR). When blood sugar levels remain elevated, NPDR can cause the retinal blood vessels to leak or even close off. If the leakage occurs near the center of the retina (macula), there can be vision loss. With PDR, the more advanced stage of DR, new blood vessels form (neovascularization) on the surface of the retina. These fragile vessels can bleed into the vitreous gel and block vision.
To properly diagnose DR, a dilated examination or extensive retinal photographs need to be performed by your eye care specialist. Many retina surgeons will also perform a fluorescein angiogram so that they can see areas of retinal swelling (macular edema) and new blood vessel growth. OCT (ocular coherence tomography) is useful for following changes in macular edema.
Treatments for DR include eye injections with ant-VEGF medications, laser surgery, and vitrectomy surgery in the operating room.
What can patients do to decrease their risk of losing vision from DR? Control the blood sugar levels and blood pressure and see your eye care specialist at the recommended intervals.
Here is another great resource on diabetic retinopathy.
Refractive eye surgery involves changing the refractive state of the eye to decrease one’s dependency on glasses or contact lenses. The first corneal refractive surgical procedure developed was radial keratotomy (RK). Corneal instability and progressive shifting of the refraction (glasses prescription) made this surgery obsolete.
LASIK (Laser-Assisted In-Situ Keratomileusis) and PRK (PhotoRefractive Keratectomy) use the excimer laser to reshape the cornea to help focus the light rays onto the retina like glasses or contact lenses do. These laser vision correction (LVC) procedures can correct nearsightedness, farsightedness, and astigmatism.
Patients who may not be good candidates for LVC:
- Thin corneas
- High glasses prescriptions
- Autoimmune diseases like rheumatoid arthritis
- People who need excellent nighttime vision, like truck drivers or airline pilots
- Currently on certain medications like Accutane/isotretinoin (or other acne medications)
- Large pupils
- History of past corneal infections
- Unstable glasses prescription
- Severe dry eyes
Presbyopia (decreased ability to see up close) starts in the mid-40s. If both eyes are lasered to correct their distance, then they will need reading glasses. Monovision is an option where one eye is set for distance and the other eye is set for or left with some nearsightedness.
Nowadays, both eyes are usually lasered in the same sitting. The first step in LASIK is to use a femtosecond laser or a micro-keratome blade to make the corneal flap. In PRK, the top layer of cells (epithelium) is carefully scraped off. The excimer laser energy is then applied to the exposed cornea to reshape it. This laser may take up to ~50 seconds per eye. If PRK was performed, then a bandage contact lens is placed to help the epithelium to grow back and for pain control. With LASIK the vision may be fairly sharp immediately after the procedure. PRK has a slower recovery because the epithelium has to grow back onto the cornea. The final results of the PRK may not be seen for several weeks. PRK may be chosen because of thin corneas and for people who are in a profession where eye injuries can occur. LASIK has become the more popular procedure because of its quicker recovery and less discomfort.
Complications may include corneal infections, intra-flap inflammation (diffuse lamellar keratitis (DLK)) in LASIK, halos at night, and difficulty driving at night. Ectasia (progressive thinning and warpage of the cornea) may be difficult to treat and the patient may need to wear hard contact lenses to improve their vision.
The ICL (Implantable Contact Lens) is a refractive intraocular lens that is placed into the area behind the iris and the natural lens. This can treat high amounts of nearsightedness and astigmatism without having to sacrifice any corneal tissue.
The SMILE (SMall Incision Lenticule Extraction) procedure utilizes the femtosecond laser to create a disc of corneal tissue that is removed. This procedure, which can correct nearsightedness and astigmatism, has not been used in the United States as much as in Europe and other countries.
Here is another great resource on Laser Vision Correction.
Oculoplastic specialist, Dr. Kenneth Cahill, joins Dr. Suh to discuss a bothersome condition – epiphora, the medical term for watering eyes. Why does excessive tearing occur and what we can do about it? Blocked tear ducts are a major cause of chronic watering.
Causes of excessive watering
- Overproduction of tears
- Abnormalities of the eyelids (ectropion (outward turning of the lower lid), entropion (in-turning of the lower lid), or lid weakness)
- Blockage of the tear drainage system (nasolacrimal duct)
- Ocular surface irritation (dry eyes, foreign body, allergies)
Tear glands on the upper part of the eyeball produce the tears. The tears will drain into the punctum, the tiny hole at the margin of each lid close to the nose. This opening leads to the canaliculus, the tube that connects the punctum to the lacrimal sac. From there the tears will end up in the nasal cavity. A blockage, temporary or permanent, can lead to excessive watering.
Symptoms of a blocked tear duct
- Tenderness and irritation of the lid margin and eyelid skin
- Crusting along the eyelash line
- Mucus build-up/discharge
- Dacryocystitis – infection of the lacrimal sac
Punctal stenosis is narrowing of the hole that can cause tearing. This can be caused by chronic use of medicated eye drops, changes from the aging process, viral infections, and dermatitis. This is treated by dilating the opening with a probe or by doing a two-snip punctoplasty to enlarge the hole. These can be performed in the office.
Causes of blocked tear ducts
- Chronic ocular irritation
- Age-related changes
- Chronic use of medicated eye drops
- Nasal trauma or polyps
- Chemotherapy medications (5-FU, Taxotere)
Congenital nasolacrimal duct obstructions are not uncommon. Usually these will spontaneously resolve within the first few months. If they do not, a quick probing procedure can open up the system.
To confirm an obstruction of the tear duct system, a probe and irrigation can be done to test for a blockage and to squirt a small amount of fluid into the system to see if it goes all the way through.
Conservative treatments for partial blocked tear ducts would include using an antibiotic/steroid eye drop and a steroid nasal spray.
There are two main surgical treatments. Silicone intubation involves putting tubing into the tear duct system and leaving it in there for 6-12 weeks. Dacryocystorhinostomy (DCR) creates an opening into the lacrimal sac and into the nose bypassing the opening in the sac that has scarred down. This is performed with local anesthesia (sometimes general anesthesia) as an outpatient surgery. Tearing usually improves within the first week. The most common complications are nose bleeds and failure to improve the tearing. DCRs have a 90-95% success rate. Conjunctivodacryocystorhinostomy (CDCR), a variant of traditional DCR, utilizes a glass (Jones) tube that is used when the canaliculi have also scarred.
Here is a great resource with videos about the topics in this episode.
On this episode Dr. George Chioran and Dr. Steven Suh answer the most common patient questions that are asked about cataracts and cataract surgery.
- What is a cataract and why do they occur?
- What symptoms do people with cataracts have?
- What are some other options before proceeding with surgery?
- How do the surgeon and the patient decide when the time is right for surgery?
- What do you tell patients who are going to have cataract surgery?
- Does insurance cover surgery?
- What are the risks of surgery? Can I go blind from cataract surgery?
- What other things are needed before surgery?
- How is the cataract removed? Do you use a laser?
- Can you do cataract surgery on both eyes on the same day?
- What should patients expect at the surgery center or hospital?
- What is the intraocular lens implant made of?
- What are the different types of lens implants available?
- What should patients expect the day after surgery?
- What post-op care is necessary? How many post-op visits?
- What restrictions are there afterwards? Do I wear a patch or shield?
- Do cataracts ever come back?
- Will the lens implants last forever?
- What kind of issues may arise after surgery?
- Will my vision change in the future?
Here is a great link on cataracts and cataract surgery.
Dr. Ashley San Filippo returns to the Healthy Eyes 101 podcast to discuss MIGS (Minimally Invasive Glaucoma Surgery), a relatively new category of glaucoma procedures that have advantages over traditional glaucoma surgeries.
Lowering eye pressure is the major goal of glaucoma treatment since this disease is not curable. Medicated eye drops, laser surgery, and traditional surgery are various ways to treat glaucoma. If patients are on maximum medical therapy with continued progression of their glaucoma, cannot tolerate the drops, or are non-compliant with taking their drops, then laser or surgical intervention may be necessary.
MIGS has given patients a new avenue of treatment that has a much quicker post-operative recovery than traditional glaucoma surgery. While most MIGS are indicated to lower eye pressure in mild-to-moderate stages of glaucoma, their safety profile is favorable to trabeculectomies and glaucoma drainage implants. MIGS work by increasing outflow of the normal eye fluid or decreasing the production of the fluid. In the United States, most of the MIGS procedures have to performed in conjunction with cataract surgery.
Trabecular bypass procedures
Trabecular tissue incision/excision procedures
Here is some more information on MIGS:
In this episode Dr. Suh interviews Dr. Chirag Patel, a retina specialist, about two conditions that can affect central vision – macula puckers and macular holes.
Patients with a macular pucker (also called epiretinal membrane, epimacular membrane, cellophane maculopathy, and surface wrinkling retinopathy) will have symptoms of distortion or blurred vision that does not go away. A pseudohole is a variant of a macular pucker that looks like a macular hole.
The majority of puckers occur spontaneously and without a cause (idiopathic). Secondary causes make up around 10-20% of cases and can be from from diabetic retinopathy, retinal vein occlusions, retinal tears and detachments, and trauma. After the age of 50, 2% of the population may have a macular pucker while 20% of people over 75 may have one. If there is a secondary reason for the pucker, this can occur at any age.
Macular holes will also cause symptoms of blurring and distortion. The patient may also notice a missing area in the center of their vision. The cause of macular holes is probably related to the vitreous gel tugging on the macular region. This traction can pull off the center part of the macula and leave a hole. Macular holes can also occur after ocular trauma. People over 60 are more likely to have a spontaneous macular hole. Females are more prone to have them than males, unlike with puckers where females and males have about the same incidence.
Diagnosis of both of these conditions can be done by direct examination of the macula and by OCT (optical coherence tomography). Patients with macular issues should monitor their vision with an Amsler grid to look for distortion or missing areas.
Medications and lasers cannot be used to treat either condition. Surgery is the only treatment. Macular pucker surgery is only performed if the patient has bothersome visual symptoms. Patients with macular holes should have surgery when the retina specialist recommends it. Visual recovery after these surgeries may be slow, and patients may not recover 20/20 vision afterwards. The surgery should improve the distortion or the missing area in the center.
Dr. Karl Pappa, a glaucoma specialist, joins Dr. Suh on this episode to discuss all aspects of glaucoma medications. Glaucoma, a disease of the optic nerve, is thought to be worsened by increased eye pressure. The goal of treatment, whether it be with eye drops, laser or surgery, is to lower the intraocular pressure (IOP).
Categories of Glaucoma Medications
- Prostaglandin analogs
- Xalatan (latanoprost), Lumigan (bimatoprost), Travatan Z (travoprost), Zioptan (tafluprost), and Vyzulta (latanoprostene bunod)
- How they lower pressure: increases the outflow of fluid
- Dosing: once at bedtime
- Main side effects: eye redness, iris color change, eyelash growth, darkening of eyelid skin
- Beta blockers
- Timolol, Timoptic XE (gel-forming solution)
- How they lower pressure: decreases production of fluid
- Dosing: once or twice a day
- Main side effects: low blood pressure, decreased pulse rate, fatigue, shortness of breath (in COPD and asthma patients), depression
- Alpha agonists
- Alphagan P (brimonidine)
- How they lower pressure: decreases production of fluid and increases drainage
- Dosing: two or three times a day
- Main side effects: allergy to the medication, fatigue/drowsiness, burning or stinging, headache, dry mouth
- Carbonic anhydrase inhibitors
- Eye drops -Trusopt (dorzolamide), Azopt (brinzolamide)
- Oral medications: Diamox (acetazolamide) and Neptazane (methazolamide)
- How they lower pressure: decreases production of fluid
- Dosing: twice a day for the drops; varies for the pills (follow instructions of your eye care specialist)
- Main side effects: eye drops: stinging; pills: tingling of hands and feet, fatigue, stomach upset
- Rho kinase inhibitor
- Rhopressa (netarsudil)
- How they lower pressure: increases the outflow of fluid
- Dosing: once at bedtime
- Main side effects: eye redness, stinging, tiny hemorrhages on the white of the eye
Combination eye drops help with compliance and may be more economical. Examples include Cosopt (timolol/dorzolamide), Combigan (timolol/brimonidine), Simbrinza (brimonidine/brinzolamide), and Rocklatan (netarsudil/latanoprost).
One reason patients have decreased compliance is because they can get ocular surface irritation and dry eyes from repeated use of drops that contain preservatives such as benzalkonium chloride (BAK). Several preservative-free options include Zioptan, Cosopt PF, and Timoptic in Ocudose.
Several new drug delivery alternatives are being studied. The FDA recently approved Durysta (bimatoprost), a biodegradable sustained-release implant that is injected into the eye between the cornea and the iris. Obviously, compliance will not be an issue with this medicated implant but it will have to be replaced every few months.
After instilling a glaucoma drop into your eye, close your eyes for up to five minutes to maximize absorption into the eyes and minimize systemic absorption to avoid some of the side effects.
Here is another resource about glaucoma drops.
This is intended for informational and educational purposes only, and nothing in this podcast/blog is to be considered as recommending or rendering medical advice or treatment to a specific patient. Please consult your eye care specialist for proper diagnosis and treatment of any eye conditions that you may have.
Retina specialist, Dr. Dominic Buzzacco, joins Dr. Suh to talk about age-related macular degeneration (AMD), one of the most common causes of central vision loss in people over 50. People with early AMD will notice distortion, blurred vision, a blind spot, or, sometimes, nothing.
Risk factors include:
- Age over age 50
- Family history (a first-degree relative increases the risk seven-fold)
- Light-colored irises
- Uncontrolled cardiovascular disease and high blood pressure
Dry (non-exudative) AMD is by far the most common type and may be associated with retinal pigmentary abnormalities and soft drusen, yellow deposits found under the retina. About 10% of dry AMD patients will progress to the wet form.
Wet (exudative or neovascular) AMD is characterized by the formation of abnormal blood vessels underneath the retina. These vessels may leak or bleed and cause scar tissue. Vision loss is more rapid with untreated wet AMD vs. the dry form.
All patients with AMD should monitor their vision in each eye individually on a regular basis by using an Amsler grid.
Patients with dry AMD should take AREDS 2 (Age-Related Eye Disease Study 2) vitamins to help slow down the progression of vision loss. Early diagnosis is important so that patients can be advised to start these eye vitamins. Patients who smoke should consider stopping.
Those with wet AMD will probably need to have intraocular injections of so-called anti-VEGF medications to slow down or stop the abnormal vessel growth. The injections may contain the medications Avastin (bevacizumab), Lucentis (ranibizumab), Eylea (aflibercept), or Beovu (brolucizumab). These injections are not a cure but can keep the leaking or bleeding under control. Most patients will need monthly injections until all fluid / bleeding is absorbed and there is no evidence of recurrence. Some may need injections every eight to twelve weeks indefinitely. These medications have been a huge leap forward to stabilizing the disease in 95% of people and improving vision in 30-40% of eyes.
Some risks of the injections include a subconjunctival hemorrhage (bruise) which goes away in a few days; temporary foreign body sensation; corneal abrasion; and intraocular infection (1:4000-5000 injections).
Most patients will never go completely blind from their AMD even if central vision deteriorates because their peripheral vision remains intact.
Some future treatments include a surgically implantable port (or reservoir) delivery system for injecting Lucentis. Gene therapy is also being studied to turn off the growth factors for abnormal blood vessels.
Unfortunately, some AMD patients may lose enough of their useful vision to perform daily activities. Low vision aids can help those with permanent vision loss. Services are available to assess the types of devices that patients may need to help them function better.
Here is another article on macular degeneration.
Dr. Sugat Patel, a retina specialist, joins Dr. Suh to discuss retinal detachments (RD), a potentially sight-threatening condition. Around 5 in 100,000 people per year will develop a retinal detachment.
A posterior vitreous detachment, separation of the liquefied vitreous gel from the retina, will occur eventually in most people. It is a major cause of flashes of light or floaters in the vision. Sometimes this may also lead to a retinal tear.
If the normal inner eye fluid (aqueous) gets under the retina through the tear, then the retina will lift off of the eye wall. This is a rhegmatogenous retinal detachment. When the retina detaches, most people will notice a scotoma, or a dark/blind spot, in their side (peripheral) vision. This scotoma may get bigger quickly and infringe on the central vision. This is an emergency and the patient needs to be evaluated by an eye care specialist immediately. Trauma and myopia (nearsightedness) are risk factors for this type of RD.
Exudative detachments occur when fluid leaks from the choroid, the nutrient layer underneath the retina. This can happen from uveitis (inflammation), bleeding, or an ocular tumor.
Tractional detachments occur when something inside the eye is pulling on the retina such as scar tissue from advanced diabetic retinopathy and retinopathy of prematurity.
Retinal tears can be treated with an in-office laser or with cryopexy (extreme cold therapy). Laser retinopexy is the more common way to treat this condition because it seals the tissue down quicker and with less inflammation.
For patients with small, asymptomatic RDs, laser retinopexy can be performed instead of surgery in the operating room. Even larger, asymptomatic RDs with tears in the upper part of the retina can be treated in the office with pneumatic retinopexy where a gas bubble is injected into the vitreous cavity to push the retina back into place. Laser or cryopexy is then used to seal down the area around the tear.
If a RD needs to be fixed in the operating room, various techniques can be used alone or together to fix the retina. A scleral buckle is a band that encircles the eye to help bring the eye wall closer to the retina. A vitrectomy is surgical removal of the vitreous gel which is what usually tugs on the retina in the first place. Laser is then used to seal the area around any retinal tears. Sometimes a gas bubble or silicone oil may be used to keep the retina in place.
All RDs need attention quickly, but macula-on detachments should be fixed more urgently because the macula is still functioning and has not separated yet. The center of the macula (fovea) is the most important area of the retina that enables one to see to read and to see details far away.
Post-operatively, patients may have some discomfort. With scleral buckles, there may be some double vision, which is usually temporary, because the buckle goes underneath the eye muscles. If a gas bubble is placed, the vision may be very fuzzy for several days. The patient may need to be in a certain head position for two to ten days to let the gas bubble push against the area where the main part of the detachment was located. The success rate for primary RD repair is around 90-95%. Some risk factors for re-detachment include younger age, trauma, and underlying inflammation.
In this tenth episode, Dr. Suh takes a departure from his usual format to interview his ophthalmology residency director and chairman, Dr. John Barber, about the three books he has written since his retirement.
His first book, The Joy of Medical Practice: Forty Years of Interesting Patients, is about the many interesting patients he has encountered from his medical school years to his last years in practice.
In his second book, Hey, Doc! What’s Wrong with My Eye?: A General Guide to Eye Symptoms, Dr. Barber writes about common symptoms and diseases of the eye and discusses treatments.
Some common causes of red eyes include:
- Conjunctivitis – often called pink eye, the translucent outer coating (conjunctiva) in front of the white part of the eye (sclera) becomes inflamed from viruses, bacteria, allergens, or chemicals
- Corneal abrasion – a scratch on the outer layer of the cornea usually from trauma
- Corneal ulcer – an infection on the cornea that can be caused by various pathogens
- Subconjunctival hemorrhage – a bruise within the conjunctival layers that can be caused by coughing, sneezing, eye rubbing, lifting heavy things, taking blood thinners, etc. Although it can be surprisingly red, it is almost always a benign condition.
- Blepharitis – inflammation of the eyelids in which they become red, irritated and itchy. It usually presents with flaky scales on the eyelashes and plugged up oil glands.
Dr. Barber’s last book is The One-Eyed Surgeon with Only One Thumb: Adventures with My Dad, Harry C. Barber, MD, FACS. He chronicles stories that his father told him as he was growing up. He recounts his life as a physician/surgeon in a small town and in Greenland during World War II.
You can find all of Dr. Barber’s books on his website.
Dr. George Chioran returns to the Healthy Eyes 101 podcast to talk about a common reason for urgent visits to the eye doctor’s office – flashes and floaters. He will be describing the different reasons why people may see flashing lights. We will then talk about the causes and risk factors for floaters and why it is important for you to be seen quickly for a dilated eye examination. We will end by discussing various treatments for when floaters cause issues with the retina.
Here is an article with a video on flashes and floaters.
On this special episode, Dr. Steven Suh and practice administrator, Laura Kunze, discuss the new procedures and protocols to ensure patient safety during their eye exam to minimize the risk of potentially spreading the coronavirus during this historic pandemic.
Please understand that this episode came out in early June of 2020 so these rules may have changed by the time you have listened to this.
Before the day of the appointment, we are pre-screening patients by asking them if they have had a sore throat, fever, fatigue, loss of smell or respiratory symptoms.
On the day of their appointment, we will check their temperature to make sure that they do not have a fever. If they do, they will be asked to re-schedule. Wearing masks are mandatory from the time they walk into the office until they leave. All doctors and staff are to wear their masks full-time as well. We ask that family members stay in their cars unless there is a need for them to accompany the patient. In the waiting room, we have placed chairs six feet apart. We are wiping down these chairs with disinfecting wipes on a regular basis.
After a patient has been in an exam or special testing room, that room is also wiped down from the chairs to the equipment, computers, and countertops. Even though we have limited the number of patient visits per day, the promptness of their appointment times may be more unpredictable because of the extra cleaning time.
Those at risk for getting seriously ill from the coronavirus may put off their appointment for their routine eye check-ups. Well-controlled glaucoma patients can generally push their appointments out one to three months, but please call if you need refills on your glaucoma drops.
If you have a new onset of symptoms such as eye pain, loss of vision, or flashes/floaters, please call for an urgent appointment. If you have a corneal infections or abrasions, an active inflammation (iritis/uveitis), diabetic retinopathy, please try to keep your regularly scheduled appointment. Those who get medications injected into their eye for wet macular degeneration, diabetic retinopathy, macular edema, or other retinal condition, please keep these appointments.
Telemedicine may be helpful for triaging for an appointment, but many conditions cannot be properly diagnosed without an actual examination with our special equipment.
Laser procedures and minor surgeries in the office should not be an issue either since everyone will be wearing a mask and cleaning protocols will be followed. Looking for glasses or getting your frames adjusted in our optical shop should not any different from before. Please do not put frames back on the boards so that we may clean them properly before the next patient tries them on.
Elective procedures such as cataract surgery in a surgery center or hospital should also be fine. They will most likely adhere to more stringent requirements including requiring coronavirus testing pre-operatively if you have had exposure to someone with COVID-19 or work in a place like a hospital where one may be exposed to people who may have the virus.
Here is another article on this topic.
In this episode Dr. Steven Suh interviews Dr. Katie Wulff about a specialty gas-permeable contact lens called scleral lenses. Some people have abnormal corneal curvatures and irregularities which make it difficult for them to see even with glasses or soft contact lenses. Stephen Curry, an NBA star with the Golden State Warriors, wears scleral lenses because of his corneal condition called keratoconus.
Rigid gas-permeable contacts (RGP) and scleral contact lenses have a smooth, spherical, and hard surface which will neutralize these irregular “hills and valleys” on one’s cornea. The reason soft contact lenses do not work as well is because they “mold” onto these corneas and do not vault over them, thus replicating the abnormal curvature. Regular RGPs can be helpful in many cases but they have limitations. Scleral lenses do not sit on the cornea like RGPs but sit on the white part of the eye (sclera) so they are usually more comfortable.
Scleral contact lenses can help maximize vision in patients with these corneal conditions:
- Pellucid marginal degeneration
- Ectasia (abnormal corneal warpage and thinning) after LASIK surgery
- Corneal scarring
- Severe dry eyes
- After corneal transplants
- Corneal irregularities after radial keratotomy (RK)
Scleral lenses are much larger than standard rigid gas-permeable and soft lenses. Since they are customized for each patient’s eye, several visits are needed to ensure that the lens is fitting properly. Inserting these lenses onto the cornea may be much more difficult than other types of contacts. Because of their potential to restore sight in many of these patients, these specialty lenses can help delay or avoid the need for corneal cross-linking or corneal transplantation.
Here is another article on scleral lenses.
Dr. Suh interviews Dr. Beckman about a debilitating, corneal thinning condition called keratoconus.
The incidence is approximately 1 in 2,000 individuals.
The major risk factors include atopic disease, Down’s Syndrome, some family history, floppy eyelid syndrome, and chronic eye rubbing.
- Initially patients may be asymptomatic
- Blurred or distorted vision from increasing nearsightedness and/or astigmatism
- Increased sensitivity to bright light and glare, which can cause problems with night driving
- A need for frequent changes in eyeglass prescriptions
- Sudden worsening or clouding of vision
Keratoconus can be diagnosed in the late teenage years and can worsen as time goes on.
Corneal topography is the main tool for diagnosis.
- Early: glasses, soft contact lenses, gas-permeable contacts, then specialty contacts called scleral lenses
- Later stages: traditional treatment has been corneal transplantation
- May have long recovery time in terms of improved vision
- Need numerous post-operative visits
- Will need a lifetime of steroid eye drops to help avoid rejection of the corneal graft
- Minor trauma can be dangerous to a post-corneal transplant eye
- May need another transplant in the future
- Corneal cross-linking
- A relatively new, in-office procedure that can slow down the progression of the thinning and warping
- Cross-linking involves treating the cornea with eye drops containing riboflavin, a B-vitamin. After the cornea has been saturated with the riboflavin, the cornea is then treated with ultraviolet light.
- Procedure time is about one hour
- Eye drops are used for only a few weeks
- Goal is to treat keratoconus early with cross-linking to hopefully prevent, or at least delay, the need for a corneal transplant in the future
Cross-linking can also treat pellucid marginal degeneration and corneal thinning (or ectasia) after LASIK.
Here is the abstract for Dr. Beckman’s cross-linking article.
On this show Dr. Suh and Dr. Julia Geldis have a thorough conversation about contact lenses.
Contact lenses have some advantages over glasses. People with higher prescriptions find that they are more comfortable from a vision standpoint because contacts do not cause as much minification or enlargement of images as with glasses. They are usually preferable when playing sports and doing other physical activities.
Dr. Geldis is comfortable with children wearing contacts as young as eight years old as long as they are mature and can take good care of them. There is no maximum age when people have to discontinue wearing contact lenses as long as their eyes are healthy, and they do not have dry eyes or other conditions that make it unsafe to wear them.
Two main types of contact lenses
- Gas permeable lenses – can give better quality vision but may be harder to adapt to initially
- Soft contact lenses – easier to get used to; most popular type
- Different options: daily disposables; two-week disposables, one-month disposables; day-and-night extended wear (have to be careful when sleeping in any kind of lenses – increased risk of infections and inflammatory conditions)
Presbyopia and contact lenses – options for seeing up close when people get into their 40s
- Reading glasses over your contacts
- Monovision – dominant eye is set for distance vision and the non-dominant eye is set for near vision
- Multi-focal lenses – both eyes will be able to see distance and near because of different refractive zones in the lenses
It is not recommended that one wear contact lenses when swimming, showering, or sleeping.
At their appointment new contact lens wearers will be taught how to put them in, take them out, and care for them.
Eye infections and inflammation are more likely to occur when people overwear them or do not clean them properly. With regards to the contact lens cases, always dispose of the old disinfecting solution – do not top it off. Rinse the inside of the case with the solution and let it air dry. Change your case every 1-3 months.
Colored contacts and “costume” contacts (popular around Halloween) are all right to wear if they are prescribed by an eye care professional.
In this era of COVID-19, always practice good hygiene when handling the lenses. If you test positive or suspect that you have this virus, please do not wear your contacts and keep your hands away from your face!
Here is another resource to learn more about about contact lenses.
On this episode Dr. Suh interviews Dr. Ashley San Filippo about primary open-angle glaucoma (POAG), the most common type of glaucoma.
Glaucoma is a progressive disease of the optic nerve (the cable–like bundle of nerve fibers that transmits visual information from the eye to the brain) that may be associated with eye pressure build-up.
There are two main types of glaucoma: open-angle and angle-closure (or narrow-angle).
Nearly three million people are affected by glaucoma in the United States.
Risk factors for open-angle glaucoma: over age 40; family history; African or Hispanic heritage; have high eye pressure; had an eye injury; used long-term steroid medications; have corneas that are thin in the center; have diabetes.
Symptoms of POAG: there may be none! Initially it is a “silent” disease. This is why it is important to have your eyes examined periodically.
Peripheral (side) vision changes precede central vision loss as the disease progresses.
The diagnosis of POAG can be confirmed in the eye doctor’s office.
- High intraocular pressure (IOP) may or may not be present because some patients never have higher than normal IOP, which is somewhere between 10 and 22 mm Hg.
- The optic nerve head (disc) has a characteristic appearance indicative of glaucomatous damage.
- Loss of side vision as measured by a visual field test.
- Optical coherence tomography (OCT) is a non-invasive imaging technique used to visualize and quantify the thickness of the nerve fiber layer of the retina and provides information on optic nerve head topography.
- Corneal thickness measurement (pachymetry) – checking for thin corneas.
Ocular hypertension is higher than ”normal” eye pressure without the other signs of glaucoma. This is one of the biggest risk factors for developing glaucoma so it is important to have regular follow-up exams with your eye care specialist.
Treatment for POAG includes medicated eye drops, laser surgery, and traditional surgery. Usually eye doctors will start with eye drops. An in-office procedure called selective laser trabeculoplasty (SLT) has become a popular option as it can lower IOP and minimize your need for eye drops. Minimally invasive glaucoma surgeries (MIGS) may be performed in conjunction with cataract surgery and is used mainly for mild to moderate glaucoma. Traditional surgeries (trabeculectomy and tube shunt drainage surgeries) are reserved for more advanced disease.
Marijuana is not an effective treatment for glaucoma.
Patients with glaucoma or who are suspicious for having glaucoma should follow the advice of their eye physician in terms of frequency of visits to ensure that they are getting all the appropriate tests to follow any changes that may be occurring.
Dr. George Chioran and Dr. Suh will be discussing bumps in the eyelids that may be acute or chronic. Chalazia and hordeola (styes), can greatly affect people when they occur because of the pain and swelling that can be present. They will talk about risk factors and what you can do to prevent these. Dr. Chioran will also review the different types of treatments that can be done from home and in the office.
- Warm compresses can be used to get rid of or help prevent these bumps. We have them for sale in our office or you can buy a commercially available eye compress here.
- These eyelid scrubs are non-abrasive cleansers that can help remove debris and bacteria from around the eyelashes and lid margins that can cause blepharitis and, ultimately, styes.
- This is an article from the American Academy of Ophthalmology about chalazion and styes.
Apocrine and epidermal inclusion cysts are also common bumps that can appear on the eyelids. They will discuss the causes and treatments of these lesions.
In this episode Dr. Suh interviews Dr. Ken Beckman about all aspects of dry eye disease. They first delve into the common signs and symptoms. Dr. Beckman then discusses the special tests that can be performed at your eye doctor’s office to confirm which type of dry eye disease you may have. Lastly, he does a comprehensive review of the wide-ranging treatments that are available today.
Below are links to some more information about topics that we discuss on the episode.
- Tear osmolarity measures the salt concentration of human tears to aid in the diagnosis of dry eye disease.
- InflammaDry detects high levels of MMP-9, an inflammatory marker that is consistently elevated in the tears of patients with chronic dry eyes.
- Lipiscan is a high-definition oil gland imager that allows eye care professionals to assess meibomian gland structure.
- This is one of the brands of moist heat eye compresses that we sell in our office to help patients with evaporative dry eyes – the most common cause of dry eye disease.
- Lipiflow is a procedure performed in our office that heats and massages the eyelids to improve outflow of the natural oil from the glands that are so vital for a stable tear film layer.
- This is a nice summary article about the three prescription dry eye medications – cyclosporine-A (Cequa and Restasis) and lifitegrast (Xiidra).
- Punctal plugs, a quick, in-office procedure covered by insurance, are a nice adjunct to combat dry eyes.
- Autologous serum drops are eye drops made from a patient’s own blood plasma and serum.
- Scleral contact lenses can be worn to treat severe dry eyes. This is an old article but still relevant.
- This is a nice summary article on dry eyes from the American Academy of Ophthalmology
- Dr. Beckman was one of the lead authors in this landmark, peer-reviewed journal article that changed paradigms about dry eyes.
Since this is a show about eye health, this first episode introduces the basics. Dr. George Chioran and Dr. Suh discuss the different parts of the eye, refractive errors (nearsightedness, farsightedness, astigmatism, and presbyopia), and the differences in the roles among the various eye care professionals (ophthalmologists, optometrists, and opticians).
This is a brief trailer to introduce Healthy Eyes 101 – a podcast for patient-centered health education focused on the eyes. The host, Steven Suh, MD, will interview the brightest ophthalmologists and optometrists to educate you about various eye conditions and their most up-to-date treatments.
This is intended for informational and educational purposes only, and nothing in this podcast/blog is to be considered as recommending or rendering medical advice or treatment to a specific patient. Please consult your eye care specialist for proper diagnosis and treatment of any eye conditions that you may have.