Dry Eye Syndrome
Some people, especially those with arthritis or an autoimmune disease, may experience dryness. Most of these people lack all the components (water, fat, and mucous). This type of dryness is usually severe and hard to manage. Most people with "dry eye syndrome" actually complain of watering. Watering eyes will usually occur if there is not enough lubricant in your tears. This lack of lubricant can cause stickiness, burning, and sometimes sharp pains. The symptoms are generally worse during activities that require concentration, like TV, driving, or reading. This is because you don't blink as much when concentrating. It may also be accompanied by redness. However, redness may indicate more serious conditions. Those experiencing dry eye syndrome require regular treatment to obtain their maximum comfort. A determination should always be made as to what causes redness in your eye.
Conjunctivitis
The conjunctiva is a transparent membrane that lines the inside portion of the lids and the white of the eye called the sclera. Any inflammation of this portion of the eye is called conjunctivitis. It is a general term and usually when this is diagnosed, the presumed cause would also be stated; for instance, allergic conjunctivitis, bacterial conjunctivitis or viral conjunctivitis. Pink eye, for instance, is a form of conjunctivitis. Some forms of conjunctivitis can be contagious, so it is always best to wash hands frequently, and avoid sharing towels, etc. Conjunctivitis can cause redness and pain, and therefore can mimic more serious problems.
Blepharitis
Blepharitis refers to a family of inflammatory disease processes of the eyelid(s).
Blepharitis can be divided anatomically into anterior and posterior blepharitis. Anterior blepharitis refers to inflammation mainly centered around the eyelashes and follicles, while the posterior variant involves the meibomian gland orifices. Anterior blepharitis usually is subdivided further into staphylococcal and seborrheic variants.
Frequently, a considerable overlap exists in these processes in individual patients. Blepharitis often is associated with systemic diseases, such as rosacea and seborrheic dermatitis, as well as ocular diseases, such as dry eye syndromes, chalazion, trichiasis, conjunctivitis, and keratitis.
Acute Glaucoma
Acute glaucoma comprises slightly less than 5% of all glaucoma cases. However, it is important to recognize the symptoms since they come on very suddenly and are associated with extreme and rapid loss of vision, redness and pain. The aqueous humor drains into Schlem's canal, which is located in the area of the eye called the anterior chamber angle. This angle can be examined only with a special lens utilizing a technique called gonioscopy. When this angle suddenly closes off and blocks the flow of fluid, the pressure rises suddenly, and if left untreated the rapid loss of vision could become a permanent condition. Other important tests are visual fields and measurement of the retinal nerve fiber layer, and the contour of the optic nerve. The pressure needs to be relieved as quickly as possible, since any vision loss will most likely be permanent. It is usually treated medically, followed as soon as possible with either laser or regular surgery.
Narrow Angle Glaucoma
This is in many ways similar to acute glaucoma, but there are more vague symptoms. The angles, where the aqueous humor drains, closes intermittently. This is sometimes accompanied by pain or discomfort, or headaches. There are even times when there are no noticeable symptoms, but the vision can slowly deteriorate just the same. Even on examination, the eyes can appear relatively normal, and the vague symptoms cannot be explained. It is particularly difficult to diagnose. When treated with laser, the patient is protected from having an acute glaucoma attack, and the vague symptoms disappear.
Chronic Glaucoma
With chronic glaucoma, there is a restriction rather than a complete blockage of the flow of aqueous humor. The aqueous humor drains into Schlem's canal, which is located in the area of the eye called the anterior chamber angle. This angle can be examined only with a special lens utilizing a technique called gonioscopy. When examined, the eye generally appears normal; however, the pressure slowly rises in spite of the normal appearance of the drainage area. This usually develops slowly and without symptoms until the condition is very advanced. There is usually no pain associated with this. Initially the vision is not affected appreciably, but in time the peripheral vision deteriorates, even to the point of "legal blindness". This type of glaucoma is thought to be inherited and it is detected on routine examination. The high pressure alone does not complete the diagnosis. A visual field examination and thorough examination of the optic nerve is necessary. Some people may have high intraocular pressures with no other signs. This condition is called ocular hypertension and requires treatment. If ocular hypertension is not treated, statistically there will be optic nerve damage within three to five years. Treatment for chronic glaucoma is either medical or surgical. When the pressure cannot be controlled, the patient cannot tolerate the medication, or if the visual field or optic nerve shows progressive deterioration, then surgery is needed. This may be performed utilizing a laser but it is also necessary in some cases to perform regular surgery for more definitive and lasting results. In extreme cases, drainage devices are surgically implanted.
Low Pressure Glaucoma
Not many years ago, glaucoma was defined simply by high pressure in the eye. Glaucoma screenings consisted of a pressure check only. We now know that pressure is only a "risk factor" for developing glaucoma. There are people with normal pressures that eventually have deterioration of the optic nerve, thinning of the retinal nerve fiber layer, restriction of the visual field, and finally, loss of vision. It is extremely important to detect and treat this before damage occurs. It can be diagnosed only by regular thorough exams.
Diabetic Retinopathy
For some people with diabetes, high blood sugar is only part of the problem. Diabetes is known to affect other parts of the body such as nerves, kidneys, and even the eyes. There are two types of changes that occur in the eyes. One is called background, or non-proliferative changes, the other proliferative changes. With background changes there is sometimes some leakage of fluid into the retina. There also may be small spot or streak-shaped hemorrhages which are located within the nerve cells or nerve fiber layer of the retina. The background changes do not alter the vision as often as the proliferative changes. In the proliferative type of diabetic retinopathy, new blood vessels form a network in the areas that are compromised. This is called a neovascular net. It is an attempt on the part of the body to bring more blood to the areas lacking oxygen. Though this is an attempt on the part of the body to heal the area, it usually does more harm than good. Another type of proliferative change is macular edema, or swelling in the central part of the retina. In many cases, especially those with proliferative changes, laser therapy is necessary. In some cases, the vision can be improved, but in most cases it merely prevents further deterioration. The type of laser and method used depends on the extent and position of the retinopathy.
Macular Degeneration
The macula is the central portion of the retina. It is in this area that one is able to see color and the most definition. When there is poor circulation, this area can deteriorate and the central vision will be affected. One does not go blind from macular degeneration since the peripheral vision is usually preserved. The symptoms are loss of the central field of vision and consequently the sharpness of vision, loss of color vision, and difficulty reading. Sometimes magnifiers are helpful for close vision. These are called low-vision aids. In some forms of macular degeneration, new blood vessels or a neovascular net, as it is called, will form to attempt to improve the circulation. This will usually make the condition worse instead of better. When this occurs, treatments are sometimes helpful. Today, we are fortunate to have a variety of treatments, including various injectable medications and various types of lasers. The advantages of some of the newer treatments is increased effectiveness, but more importantly, less healthy tissue is compromised. It must be remembered that these treatments are a means of arresting the progression of the problem and do not always restore vision already lost. There have been studies showing that vitamins, especially the antioxidants, have a beneficial effect on the retina. Keep in mind that they are not curative, but preventative; and the longer one takes these vitamins, the more protection they will have. Furthermore, it is always best to choose vitamins in liquid or capsule form for best absorption. Many vitamins in tablet form are not always the highest quality, and with the coatings designed to give longer shelf life, they often do not dissolve properly when swallowed.
Vitreous Floaters
Some people see spots or clumps moving in front of their eyes. We call these "vitreous floaters." The vitreous humor is the jelly-like substance that fills the cavity of the eye. These spots float about and form shadows on the retina in the back of the eye. Sometimes other conditions involving the vitreous gel can cause the sensation of flashes of light. Vitreous floaters and flashes are normally harmless, however they may be a sign of a more serious problem, such as a hemorrhage, retinal tear or a retinal detachment. Only an examination by your ophthalmologist can determine which flashes or floaters are serious.
Retinal Detachment
The retina is the nerve layer that lines the back of the eye. Its blood supply and nourishment come from behind it. When the retina detaches from the back of the eye, it bulges into the cavity of the eye and therefore is separated from its blood supply. The vision is lost in that area, and if left untreated the vision is permanently damaged. Retinal detachments are frequently associated with holes or tears in the retina. They may be caused by various conditions including trauma. Most often there are no symptoms except for a blurred or obscured area in the field of vision. This clouded area does not change and in many cases progresses, becoming worse. By comparison, vitreous floaters will cause areas of decreased vision which move about and will frequently come and go. The loss in a retinal detachment can be permanent, and must be treated. Some people may notice flashes of light or a sudden increase in vitreous floaters prior to having a retinal detachment. It is always necessary to treat a retinal detachment surgically as soon as possible.
Ptosis
Ptosis is a condition where the lids droop. This can be congenital or acquired. it may occur after cataract surgery and the reason for this is not fully understood. Surgery may be needed to raise them. It is important to determine whether the muscle or nerve is responsible for the ptosis. With nerve problems, medication and not surgery may be indicated. With muscle problems, surgery is usually successful. The type and extent of surgery is determined by the amount of residual muscle tone and the amount of correction needed. Most lid surgery is considered cosmetic. When vision is affected and this can be documented, then surgery can be considered medically necessary to restore function.
Entropion and Ectropion
Entropion is a condition in which the lids turn in and ectropion is when the lids turn out. Both of these can cause serious eye problems. When the lid turns in, the lashes rub and scratch the eye. When the lid turns out, there is drying of the eye surface. The most serious complication of either of these problems is ulceration, and this could actually lead to the loss of the eye in extreme cases. Sometimes, lubricants and massage can correct this, but surgery is most often required.
Pterygium
A pterygium is a growth on the white of the eye very close to and sometimes into the clear cornea. These are usually benign growths and are made up mostly of fatty tissue. They are generally very slow growing and it is believed that sunlight influences the progression. There are many blood vessels in the area of pterygium, which can become very prominent even with very minor irritation. These are unsightly and unfortunately medication does not correct it. Surgery is needed if the pterygium is very symptomatic, or grows into the clear cornea. Even with complete removal, there is still a very high incidence of recurrence, and there may still be some redness in the area. To minimize the chance of recurrence, an anti-cancer drug called Mitomycin-C, and amniotic membrane or conjunctival grafts are frequently used at the time of surgery.
Subconjunctival Hemorrhage
Sometimes a small hemorrhage can occur in the membrane covering the white of the eye. In this area, even a small amount of blood will spread through the tissue and appear very large. These generally will occur spontaneously and without any symptoms. Very often a person will wake up with it and discover its presence only when looking in the mirror. It is rather frightening, but certainly not serious. Initially, cold compresses can be used to prevent further oozing of blood. After the first day, hot compresses can be used to increase the absorption rate. As a rule, no medical treatment is required. If they are recurrent then further investigation may be necessary.
Chalazion
A chalazion is an inflammation in the lid. It is very similar to a stye, but generally occurs deeper in the lid tissue. It is believed that they occur when the glands on the margin of the lid become blocked. These are very annoying and sometimes unsightly, but are not serious. Treatment consists of frequent hot compresses and sometimes topical or oral antibiotics. In 80% of the cases, they will resolve within 6-8 weeks. When they persist, then surgery is required. Any lesion which recurs after removal, or which persists on the surface of the lid, should be examined for the presence of cancer cells. When cancer cells are found, surgery is always needed.
Foreign Body
Nearly everyone knows what it is like to have something in the eye. Depending on the type of substance and the manner in which it enters the eye, foreign bodies could be anything from a minor nuisance to a serious threat to vision. If a foreign body cannot be removed by manipulating the lids or irrigating the eye, then it should be covered and medical treatment sought as soon as possible. If a foreign body has entered the eye at a high velocity, for instance while operating any machinery such as grinders, lawn mowers, etc., then there is a possibility of perforation of the eye. In any situation where there has been sharp trauma or a foreign body has entered the eye at high velocity, no attempt should be made at irrigation or treatment. The eye should be covered so as to protect it from further damage, and the patient should report immediately to an emergency room.
Blunt Trauma
With blunt trauma, the eye could easily be ruptured, especially if there has been a direct blow to the eye. Most often, fortunately, this is not the case, and the trauma is absorbed by the bone around the eye. Even so, these types of injuries can be very serious. If there is a suspicion of the eye itself being ruptured, it should be covered so as to prevent further damage. The patient should then immediately report to an emergency room. When blunt trauma has merely affected the surrounding tissues, the eye still may react, causing light sensitivity and a condition known as iritis. There can also be a fracture of the bone around the eye which may also interfere indirectly with sight. With any of these instances, it is best to be checked at an emergency room. It is also important to be checked periodically after trauma, since there is a greater incidence of glaucoma developing later.
Chemical Burns
Burns from lye, acid, petroleum products and other harsh chemicals occur very frequently. The most important thing to remember with any chemical burn is that the initial first-aid treatment is crucial in saving the eyesight. Proper first-aid consists of irrigation with plain water in order to flush the chemical from the eye. The easiest way to accomplish this is to place the head directly under the faucet using a steady stream of water. It is best to continue this for about 10 minutes before even trying to go for medical help. It is then still considered an urgent matter, and one should go to the nearest emergency room.
Warning Signs
Any sudden loss of vision or loss of a portion of the visual field could signal a serious problem. This should be checked as soon as possible. If there is rapid onset of pain associated with decreased vision and redness, one should be checked as soon as possible, preferably the same day. Other less urgent signs are crossing of the eyes, double vision, flashes of light, or the occurrence of or an increase in floaters. These may not be of as urgent a nature, but should still be checked by an ophthalmologist.
Introduction to Contact
Lenses Modern technology has opened the world of contact lens vision correction to nearly everyone. Today we can correct all types of vision problems through the use of soft or rigid lenses. If you are nearsighted, farsighted, have astigmatism which is an irregular curve to the eye, or even require bifocals, you can now enjoy freedom from glasses with the natural, comfortable vision of contact lenses. The various options should be discussed with your doctor. Depending on the type or lens needed, the cost will vary. Unlike glasses, contact lenses come in contact with the eyes and therefore it is important to use the best quality lenses with a professional fitting and follow-up to minimize and avoid problems. Unlike glasses, one needs a trial fitting to determine the contact lens prescription.
Soft Contact Lenses
Soft contact lenses are hydrophilic, meaning "containing water." The water content in the lens is an important determining factor in how the lens functions. Other factors, like oxygen transmission, are also important. Today, even people with dry eye syndrome can often be successful contact lens wearers. These soft plastic lenses can now correct almost all vision problems such as myopia or nearsightedness, hyperopia or farsightedness, astigmatism which is an irregular curve of the eye, and even bifocal correction. They are the easiest for most eyes to adapt to. Many come in colors, and there are daily, weekly, and monthly replacement lenses. Although many are designed for extended wear, it is still best to remove them at night. It is extremely important when storing lenses to clean the case and change the solution every day. The disinfecting solutions are not strong enough to last more than a day. A trial fitting is necessary to determine the prescription.
Rigid Contact
Lenses First produced in the late 1800s, rigid or hard contacts were the first type of contact lenses to be used. They were manufactured then from hard Plexiglas types of plastic, but have evolved now into semi-hard silicone types of plastic called gas-permeables. These small buttons of plastic allow necessary oxygen and gases to reach the cornea or the clear window of the eye. Although the typical period required by the patient to adapt to hard lenses is longer initially, the superior optics and ease of maintenance of the rigid gas-permeables often make them the desirable choice for vision correction. Some types of astigmatism, an irregular curvature of the eye, can only be corrected with gas permeable lenses. Another advantage is that they can last for years with proper care. A trial fitting is necessary to determine the prescription. Most rigid gas-permeable lenses are for daily wear. It is extremely important when storing lenses to clean the case and change the solution every day. The disinfecting solutions are not strong enough to last more than a day.
Sunglasses
Questions are frequently asked like "Are sunglasses necessary?" "If so, should they be worn at all times?" "Which colors are best?" "How dark should they be?" "Is ultraviolet light harmful to the eye and should it be filtered out with the sunglasses?" Ultraviolet (UV) light does have a detrimental effect on the retina over time, so it is important to block it. The amount of tint or the color of the lens is generally left to personal preference. The gray tint filters out light most evenly through the visual spectrum, and is the most popular color. The next most popular is amber and after that, green. Some people claim that their vision and color perception is enhanced by the amber color. Some people are naturally more sensitive to bright light than others and rely more on sunglasses. The lens of the eye filters out the harmful portion of the ultraviolet light, but it can contribute to cataracts. It is therefore advisable to wear sunglasses to obtain maximum protection. The best sunglasses not only block UV light, but are polarized and have an antireflective coating to increase the effectiveness.
What is a Cataract?
A cataract is a clouding of the lens of the eye. When one looks at the eye, the very front part is clear, called the cornea. A little deeper one finds the colored portion or iris. In the center of the iris is a the pupil or opening which adjusts the light. Just behind the pupil is the lens. Cataracts can be classified in different ways. They can occur at any age and be present in any part of the lens. They may be present at birth or shortly after, which would be congenital in nature. They can form from disease and illness such as diabetes. They may also occur as a result of trauma. By and large, however, most cataracts are due to the aging process of the lens. When cataracts affect the vision they require surgical removal. Most often, a lens implant is placed.
Lens Implants
Cataract surgery is actually the removal of the lens. The eye can be compared to a camera. The lens focuses images sharply on the retina. When the clouding or cataract occurs, the lens is no longer able to focus clearly onto the retina. After surgery, the eye is unable to focus because it needs a lens to function again normally. The alternatives are cataract glasses which are thick and heavy, a contact lens which is worn on the eye, or a lens implant or intraocular lens which is an artificial lens placed within the eye. With the glasses, the depth perception is altered, the peripheral vision is restricted, and if the other eye sees well, a balance is very difficult to achieve. Contact lenses, on the other hand, do give good peripheral vision and good balance. They do not alter depth perception. However, many people find it difficult or impossible to insert and others may not tolerate them at all. Intraocular lenses or lens implants give the same advantages as contact lenses but do not have to be handled. They are surgically placed within the eyes. Some people function quite well with just the implants while most people require some refinement of vision through glasses. When this is necessary, the glasses are at least ordinary, not thick and heavy. Lens implants are also used on a small percentage of patients without cataracts who wish to reduce the need for glasses or contact lenses, and who are not candidates for laser correction.
We are fortunate today to have multifocal implants available. This allows the patient to see distance, intermediate, and close usually without glasses. With monofocal implants, approximately 70% of patients will wear part time glasses. With the multifocal implants, about 10% of patients will have part time glasses. Most insurances do not cover the entire cost of the multifocal, nor the extra pre and post operative care. Furthermore, not everyone wanting one is a good candidate for it, and a small percentage of patients may need further surgery to optimize the result. These choices are best discussed with your Ophthalmologist.
Secondary Implants
There are some people who have had their cataracts removed in the past without the placement of an intraocular lens. There are many reasons why this may have been done. The patient most likely wore thick glasses or contact lenses to restore vision. If the glasses or contacts cannot be tolerated, sometimes, an intraocular lens can be inserted later. Only your Ophthalmologist can determine if this is feasible.
Post-Operative Care
It is generally agreed that the postoperative period is as important as the surgery itself. This care is usually rendered by the surgeon who operated, but can be done by any competent eye care professional. This shared responsibility needs to be arranged in advance with the consent of all parties. For the period specified by the doctor, the patient should avoid unnecessary strain, should place any medication prescribed as directed, protect the eye with either a shield or glasses and keep the necessary follow-up visits. Any unusual pain, clouded vision, or extreme redness should be reported.
Secondary Membrane or After Cataract
In most cases, when cataracts are removed, the front portion of the capsule of the lens is removed, the contents of the lens is suctioned out, and the back capsule called the posterior capsule is left in place. This is done because it is safer for the retina, and in most cases will help support an intraocular lens implant. The capsule is purposely left intact in spite of the fact that it will often cloud in time. Sometimes this clouding occurs within months of surgery, but in most cases it is within a 3-4 year period. This clouding of the posterior capsule is called secondary membrane or simply an after cataract. It is not exactly a cataract, but it does act in the same manner. When the vision is affected significantly by this membrane, the YAG laser is often used to open a small hole in the center.
Presbyopia
Most people will require reading glasses as they get older. This normal change in the eyes is called presbyopia. It is usually corrected by glasses or contact lenses; however, today there are surgical methods that can reduce or eliminate the need for glasses or contacts. Some of these procedures utilize lasers, or radio waves, but in select patients, multifocal lens implants may be the best choice.
Excimer Laser
A number of procedures are available for the purpose of reducing or eliminating the need for glasses or contacts. This is called refractive surgery. Most people are familiar with Lasik, which is only one method utilizing the excimer laser. With these procedures, the cornea is reshaped. In order to determine if one is a candidate for any of these, various measurements must be taken first. Your Ophthalmologist would then decide which type of surgery would offer the best chance of success.
Radial Keratotomy
Radial Keratotomy is a surgical procedure designed to correct low to moderate amounts of myopia or nearsightedness. By modification in technique, farsightedness and varying degrees of astigmatism, which is an irregular curve to the eye, can also be corrected. By making incisions from the central optic zone out to the periphery of the cornea, the length of the eye is altered and the focusing power is altered. This procedure was developed in Russia and further refined in the United States. Very careful measurements are taken of the thickness of the cornea, the refractive state of the eye, and the size of the central optic zone. Today, RK is rarely done, and has been replaced by other more predictable procedures. However, a variation of RK, called astigmatic keratotomy or limbal relaxing incisions, is performed often during cataract surgery to reduce astigmatism.
Corneal Transplants
The cornea is the clear window in the very front part of the eye. It can be compared to a watch crystal. Sometimes the cornea becomes clouded and impairs vision. There are many causes of this cloudiness. Sometimes it can be congenital, due to disease, or due to trauma. Corneal cloudiness is also seen in patients who have had eye surgery. In many cases, the only treatment is corneal transplant surgery. This involves removing the central part of the cornea and sewing in donated human cornea. Depending upon the condition which caused the clouding, the success rate is most often quite high. It does involve a great deal of surgical expertise to perform, and the postoperative period is long and involved. In the last few years, there have been significant advances in the management of corneal disorders. One exciting technique is called "Decemets' stripping endothelial keratoplasty" or DSEK. This has greatly shortened recovery time.
This area of Ophthalmology is rapidly evolving, getting simpler, safer, and more effective. When this surgery is indicated, it is best to review the current options with your Ophthalmologist.
Laser Surgery
Various lasers are used more and more in all fields of medicine. Particularly with ophthalmology lasers have become extremely important in treatment and prevention of disease. When light shines through certain substances, its energy level is increased. Depending on the substance used, various qualities of laser can be produced. The decision to use a certain laser for a certain problem is determined by the tissue's ability to absorb a particular laser light. The goal is to focus the laser light on the tissue being treated without damaging the portions of the eye that it passes through or the surrounding tissue. Therefore it is important to consider the duration of the laser, the color or type of light, the heat generated, the number of pulses, etc. The types of laser discussed in Eyeline are the Excimer, the YAG and the Argon. These are by no means the only type, but they are the most commonly used at this time.
Some people, especially those with arthritis or an autoimmune disease, may experience dryness. Most of these people lack all the components (water, fat, and mucous). This type of dryness is usually severe and hard to manage. Most people with "dry eye syndrome" actually complain of watering. Watering eyes will usually occur if there is not enough lubricant in your tears. This lack of lubricant can cause stickiness, burning, and sometimes sharp pains. The symptoms are generally worse during activities that require concentration, like TV, driving, or reading. This is because you don't blink as much when concentrating. It may also be accompanied by redness. However, redness may indicate more serious conditions. Those experiencing dry eye syndrome require regular treatment to obtain their maximum comfort. A determination should always be made as to what causes redness in your eye.
Conjunctivitis
The conjunctiva is a transparent membrane that lines the inside portion of the lids and the white of the eye called the sclera. Any inflammation of this portion of the eye is called conjunctivitis. It is a general term and usually when this is diagnosed, the presumed cause would also be stated; for instance, allergic conjunctivitis, bacterial conjunctivitis or viral conjunctivitis. Pink eye, for instance, is a form of conjunctivitis. Some forms of conjunctivitis can be contagious, so it is always best to wash hands frequently, and avoid sharing towels, etc. Conjunctivitis can cause redness and pain, and therefore can mimic more serious problems.
Blepharitis
Blepharitis refers to a family of inflammatory disease processes of the eyelid(s).
Blepharitis can be divided anatomically into anterior and posterior blepharitis. Anterior blepharitis refers to inflammation mainly centered around the eyelashes and follicles, while the posterior variant involves the meibomian gland orifices. Anterior blepharitis usually is subdivided further into staphylococcal and seborrheic variants.
Frequently, a considerable overlap exists in these processes in individual patients. Blepharitis often is associated with systemic diseases, such as rosacea and seborrheic dermatitis, as well as ocular diseases, such as dry eye syndromes, chalazion, trichiasis, conjunctivitis, and keratitis.
Acute Glaucoma
Acute glaucoma comprises slightly less than 5% of all glaucoma cases. However, it is important to recognize the symptoms since they come on very suddenly and are associated with extreme and rapid loss of vision, redness and pain. The aqueous humor drains into Schlem's canal, which is located in the area of the eye called the anterior chamber angle. This angle can be examined only with a special lens utilizing a technique called gonioscopy. When this angle suddenly closes off and blocks the flow of fluid, the pressure rises suddenly, and if left untreated the rapid loss of vision could become a permanent condition. Other important tests are visual fields and measurement of the retinal nerve fiber layer, and the contour of the optic nerve. The pressure needs to be relieved as quickly as possible, since any vision loss will most likely be permanent. It is usually treated medically, followed as soon as possible with either laser or regular surgery.
Narrow Angle Glaucoma
This is in many ways similar to acute glaucoma, but there are more vague symptoms. The angles, where the aqueous humor drains, closes intermittently. This is sometimes accompanied by pain or discomfort, or headaches. There are even times when there are no noticeable symptoms, but the vision can slowly deteriorate just the same. Even on examination, the eyes can appear relatively normal, and the vague symptoms cannot be explained. It is particularly difficult to diagnose. When treated with laser, the patient is protected from having an acute glaucoma attack, and the vague symptoms disappear.
Chronic Glaucoma
With chronic glaucoma, there is a restriction rather than a complete blockage of the flow of aqueous humor. The aqueous humor drains into Schlem's canal, which is located in the area of the eye called the anterior chamber angle. This angle can be examined only with a special lens utilizing a technique called gonioscopy. When examined, the eye generally appears normal; however, the pressure slowly rises in spite of the normal appearance of the drainage area. This usually develops slowly and without symptoms until the condition is very advanced. There is usually no pain associated with this. Initially the vision is not affected appreciably, but in time the peripheral vision deteriorates, even to the point of "legal blindness". This type of glaucoma is thought to be inherited and it is detected on routine examination. The high pressure alone does not complete the diagnosis. A visual field examination and thorough examination of the optic nerve is necessary. Some people may have high intraocular pressures with no other signs. This condition is called ocular hypertension and requires treatment. If ocular hypertension is not treated, statistically there will be optic nerve damage within three to five years. Treatment for chronic glaucoma is either medical or surgical. When the pressure cannot be controlled, the patient cannot tolerate the medication, or if the visual field or optic nerve shows progressive deterioration, then surgery is needed. This may be performed utilizing a laser but it is also necessary in some cases to perform regular surgery for more definitive and lasting results. In extreme cases, drainage devices are surgically implanted.
Low Pressure Glaucoma
Not many years ago, glaucoma was defined simply by high pressure in the eye. Glaucoma screenings consisted of a pressure check only. We now know that pressure is only a "risk factor" for developing glaucoma. There are people with normal pressures that eventually have deterioration of the optic nerve, thinning of the retinal nerve fiber layer, restriction of the visual field, and finally, loss of vision. It is extremely important to detect and treat this before damage occurs. It can be diagnosed only by regular thorough exams.
Diabetic Retinopathy
For some people with diabetes, high blood sugar is only part of the problem. Diabetes is known to affect other parts of the body such as nerves, kidneys, and even the eyes. There are two types of changes that occur in the eyes. One is called background, or non-proliferative changes, the other proliferative changes. With background changes there is sometimes some leakage of fluid into the retina. There also may be small spot or streak-shaped hemorrhages which are located within the nerve cells or nerve fiber layer of the retina. The background changes do not alter the vision as often as the proliferative changes. In the proliferative type of diabetic retinopathy, new blood vessels form a network in the areas that are compromised. This is called a neovascular net. It is an attempt on the part of the body to bring more blood to the areas lacking oxygen. Though this is an attempt on the part of the body to heal the area, it usually does more harm than good. Another type of proliferative change is macular edema, or swelling in the central part of the retina. In many cases, especially those with proliferative changes, laser therapy is necessary. In some cases, the vision can be improved, but in most cases it merely prevents further deterioration. The type of laser and method used depends on the extent and position of the retinopathy.
Macular Degeneration
The macula is the central portion of the retina. It is in this area that one is able to see color and the most definition. When there is poor circulation, this area can deteriorate and the central vision will be affected. One does not go blind from macular degeneration since the peripheral vision is usually preserved. The symptoms are loss of the central field of vision and consequently the sharpness of vision, loss of color vision, and difficulty reading. Sometimes magnifiers are helpful for close vision. These are called low-vision aids. In some forms of macular degeneration, new blood vessels or a neovascular net, as it is called, will form to attempt to improve the circulation. This will usually make the condition worse instead of better. When this occurs, treatments are sometimes helpful. Today, we are fortunate to have a variety of treatments, including various injectable medications and various types of lasers. The advantages of some of the newer treatments is increased effectiveness, but more importantly, less healthy tissue is compromised. It must be remembered that these treatments are a means of arresting the progression of the problem and do not always restore vision already lost. There have been studies showing that vitamins, especially the antioxidants, have a beneficial effect on the retina. Keep in mind that they are not curative, but preventative; and the longer one takes these vitamins, the more protection they will have. Furthermore, it is always best to choose vitamins in liquid or capsule form for best absorption. Many vitamins in tablet form are not always the highest quality, and with the coatings designed to give longer shelf life, they often do not dissolve properly when swallowed.
Vitreous Floaters
Some people see spots or clumps moving in front of their eyes. We call these "vitreous floaters." The vitreous humor is the jelly-like substance that fills the cavity of the eye. These spots float about and form shadows on the retina in the back of the eye. Sometimes other conditions involving the vitreous gel can cause the sensation of flashes of light. Vitreous floaters and flashes are normally harmless, however they may be a sign of a more serious problem, such as a hemorrhage, retinal tear or a retinal detachment. Only an examination by your ophthalmologist can determine which flashes or floaters are serious.
Retinal Detachment
The retina is the nerve layer that lines the back of the eye. Its blood supply and nourishment come from behind it. When the retina detaches from the back of the eye, it bulges into the cavity of the eye and therefore is separated from its blood supply. The vision is lost in that area, and if left untreated the vision is permanently damaged. Retinal detachments are frequently associated with holes or tears in the retina. They may be caused by various conditions including trauma. Most often there are no symptoms except for a blurred or obscured area in the field of vision. This clouded area does not change and in many cases progresses, becoming worse. By comparison, vitreous floaters will cause areas of decreased vision which move about and will frequently come and go. The loss in a retinal detachment can be permanent, and must be treated. Some people may notice flashes of light or a sudden increase in vitreous floaters prior to having a retinal detachment. It is always necessary to treat a retinal detachment surgically as soon as possible.
Ptosis
Ptosis is a condition where the lids droop. This can be congenital or acquired. it may occur after cataract surgery and the reason for this is not fully understood. Surgery may be needed to raise them. It is important to determine whether the muscle or nerve is responsible for the ptosis. With nerve problems, medication and not surgery may be indicated. With muscle problems, surgery is usually successful. The type and extent of surgery is determined by the amount of residual muscle tone and the amount of correction needed. Most lid surgery is considered cosmetic. When vision is affected and this can be documented, then surgery can be considered medically necessary to restore function.
Entropion and Ectropion
Entropion is a condition in which the lids turn in and ectropion is when the lids turn out. Both of these can cause serious eye problems. When the lid turns in, the lashes rub and scratch the eye. When the lid turns out, there is drying of the eye surface. The most serious complication of either of these problems is ulceration, and this could actually lead to the loss of the eye in extreme cases. Sometimes, lubricants and massage can correct this, but surgery is most often required.
Pterygium
A pterygium is a growth on the white of the eye very close to and sometimes into the clear cornea. These are usually benign growths and are made up mostly of fatty tissue. They are generally very slow growing and it is believed that sunlight influences the progression. There are many blood vessels in the area of pterygium, which can become very prominent even with very minor irritation. These are unsightly and unfortunately medication does not correct it. Surgery is needed if the pterygium is very symptomatic, or grows into the clear cornea. Even with complete removal, there is still a very high incidence of recurrence, and there may still be some redness in the area. To minimize the chance of recurrence, an anti-cancer drug called Mitomycin-C, and amniotic membrane or conjunctival grafts are frequently used at the time of surgery.
Subconjunctival Hemorrhage
Sometimes a small hemorrhage can occur in the membrane covering the white of the eye. In this area, even a small amount of blood will spread through the tissue and appear very large. These generally will occur spontaneously and without any symptoms. Very often a person will wake up with it and discover its presence only when looking in the mirror. It is rather frightening, but certainly not serious. Initially, cold compresses can be used to prevent further oozing of blood. After the first day, hot compresses can be used to increase the absorption rate. As a rule, no medical treatment is required. If they are recurrent then further investigation may be necessary.
Chalazion
A chalazion is an inflammation in the lid. It is very similar to a stye, but generally occurs deeper in the lid tissue. It is believed that they occur when the glands on the margin of the lid become blocked. These are very annoying and sometimes unsightly, but are not serious. Treatment consists of frequent hot compresses and sometimes topical or oral antibiotics. In 80% of the cases, they will resolve within 6-8 weeks. When they persist, then surgery is required. Any lesion which recurs after removal, or which persists on the surface of the lid, should be examined for the presence of cancer cells. When cancer cells are found, surgery is always needed.
Foreign Body
Nearly everyone knows what it is like to have something in the eye. Depending on the type of substance and the manner in which it enters the eye, foreign bodies could be anything from a minor nuisance to a serious threat to vision. If a foreign body cannot be removed by manipulating the lids or irrigating the eye, then it should be covered and medical treatment sought as soon as possible. If a foreign body has entered the eye at a high velocity, for instance while operating any machinery such as grinders, lawn mowers, etc., then there is a possibility of perforation of the eye. In any situation where there has been sharp trauma or a foreign body has entered the eye at high velocity, no attempt should be made at irrigation or treatment. The eye should be covered so as to protect it from further damage, and the patient should report immediately to an emergency room.
Blunt Trauma
With blunt trauma, the eye could easily be ruptured, especially if there has been a direct blow to the eye. Most often, fortunately, this is not the case, and the trauma is absorbed by the bone around the eye. Even so, these types of injuries can be very serious. If there is a suspicion of the eye itself being ruptured, it should be covered so as to prevent further damage. The patient should then immediately report to an emergency room. When blunt trauma has merely affected the surrounding tissues, the eye still may react, causing light sensitivity and a condition known as iritis. There can also be a fracture of the bone around the eye which may also interfere indirectly with sight. With any of these instances, it is best to be checked at an emergency room. It is also important to be checked periodically after trauma, since there is a greater incidence of glaucoma developing later.
Chemical Burns
Burns from lye, acid, petroleum products and other harsh chemicals occur very frequently. The most important thing to remember with any chemical burn is that the initial first-aid treatment is crucial in saving the eyesight. Proper first-aid consists of irrigation with plain water in order to flush the chemical from the eye. The easiest way to accomplish this is to place the head directly under the faucet using a steady stream of water. It is best to continue this for about 10 minutes before even trying to go for medical help. It is then still considered an urgent matter, and one should go to the nearest emergency room.
Warning Signs
Any sudden loss of vision or loss of a portion of the visual field could signal a serious problem. This should be checked as soon as possible. If there is rapid onset of pain associated with decreased vision and redness, one should be checked as soon as possible, preferably the same day. Other less urgent signs are crossing of the eyes, double vision, flashes of light, or the occurrence of or an increase in floaters. These may not be of as urgent a nature, but should still be checked by an ophthalmologist.
Introduction to Contact
Lenses Modern technology has opened the world of contact lens vision correction to nearly everyone. Today we can correct all types of vision problems through the use of soft or rigid lenses. If you are nearsighted, farsighted, have astigmatism which is an irregular curve to the eye, or even require bifocals, you can now enjoy freedom from glasses with the natural, comfortable vision of contact lenses. The various options should be discussed with your doctor. Depending on the type or lens needed, the cost will vary. Unlike glasses, contact lenses come in contact with the eyes and therefore it is important to use the best quality lenses with a professional fitting and follow-up to minimize and avoid problems. Unlike glasses, one needs a trial fitting to determine the contact lens prescription.
Soft Contact Lenses
Soft contact lenses are hydrophilic, meaning "containing water." The water content in the lens is an important determining factor in how the lens functions. Other factors, like oxygen transmission, are also important. Today, even people with dry eye syndrome can often be successful contact lens wearers. These soft plastic lenses can now correct almost all vision problems such as myopia or nearsightedness, hyperopia or farsightedness, astigmatism which is an irregular curve of the eye, and even bifocal correction. They are the easiest for most eyes to adapt to. Many come in colors, and there are daily, weekly, and monthly replacement lenses. Although many are designed for extended wear, it is still best to remove them at night. It is extremely important when storing lenses to clean the case and change the solution every day. The disinfecting solutions are not strong enough to last more than a day. A trial fitting is necessary to determine the prescription.
Rigid Contact
Lenses First produced in the late 1800s, rigid or hard contacts were the first type of contact lenses to be used. They were manufactured then from hard Plexiglas types of plastic, but have evolved now into semi-hard silicone types of plastic called gas-permeables. These small buttons of plastic allow necessary oxygen and gases to reach the cornea or the clear window of the eye. Although the typical period required by the patient to adapt to hard lenses is longer initially, the superior optics and ease of maintenance of the rigid gas-permeables often make them the desirable choice for vision correction. Some types of astigmatism, an irregular curvature of the eye, can only be corrected with gas permeable lenses. Another advantage is that they can last for years with proper care. A trial fitting is necessary to determine the prescription. Most rigid gas-permeable lenses are for daily wear. It is extremely important when storing lenses to clean the case and change the solution every day. The disinfecting solutions are not strong enough to last more than a day.
Sunglasses
Questions are frequently asked like "Are sunglasses necessary?" "If so, should they be worn at all times?" "Which colors are best?" "How dark should they be?" "Is ultraviolet light harmful to the eye and should it be filtered out with the sunglasses?" Ultraviolet (UV) light does have a detrimental effect on the retina over time, so it is important to block it. The amount of tint or the color of the lens is generally left to personal preference. The gray tint filters out light most evenly through the visual spectrum, and is the most popular color. The next most popular is amber and after that, green. Some people claim that their vision and color perception is enhanced by the amber color. Some people are naturally more sensitive to bright light than others and rely more on sunglasses. The lens of the eye filters out the harmful portion of the ultraviolet light, but it can contribute to cataracts. It is therefore advisable to wear sunglasses to obtain maximum protection. The best sunglasses not only block UV light, but are polarized and have an antireflective coating to increase the effectiveness.
What is a Cataract?
A cataract is a clouding of the lens of the eye. When one looks at the eye, the very front part is clear, called the cornea. A little deeper one finds the colored portion or iris. In the center of the iris is a the pupil or opening which adjusts the light. Just behind the pupil is the lens. Cataracts can be classified in different ways. They can occur at any age and be present in any part of the lens. They may be present at birth or shortly after, which would be congenital in nature. They can form from disease and illness such as diabetes. They may also occur as a result of trauma. By and large, however, most cataracts are due to the aging process of the lens. When cataracts affect the vision they require surgical removal. Most often, a lens implant is placed.
Lens Implants
Cataract surgery is actually the removal of the lens. The eye can be compared to a camera. The lens focuses images sharply on the retina. When the clouding or cataract occurs, the lens is no longer able to focus clearly onto the retina. After surgery, the eye is unable to focus because it needs a lens to function again normally. The alternatives are cataract glasses which are thick and heavy, a contact lens which is worn on the eye, or a lens implant or intraocular lens which is an artificial lens placed within the eye. With the glasses, the depth perception is altered, the peripheral vision is restricted, and if the other eye sees well, a balance is very difficult to achieve. Contact lenses, on the other hand, do give good peripheral vision and good balance. They do not alter depth perception. However, many people find it difficult or impossible to insert and others may not tolerate them at all. Intraocular lenses or lens implants give the same advantages as contact lenses but do not have to be handled. They are surgically placed within the eyes. Some people function quite well with just the implants while most people require some refinement of vision through glasses. When this is necessary, the glasses are at least ordinary, not thick and heavy. Lens implants are also used on a small percentage of patients without cataracts who wish to reduce the need for glasses or contact lenses, and who are not candidates for laser correction.
We are fortunate today to have multifocal implants available. This allows the patient to see distance, intermediate, and close usually without glasses. With monofocal implants, approximately 70% of patients will wear part time glasses. With the multifocal implants, about 10% of patients will have part time glasses. Most insurances do not cover the entire cost of the multifocal, nor the extra pre and post operative care. Furthermore, not everyone wanting one is a good candidate for it, and a small percentage of patients may need further surgery to optimize the result. These choices are best discussed with your Ophthalmologist.
Secondary Implants
There are some people who have had their cataracts removed in the past without the placement of an intraocular lens. There are many reasons why this may have been done. The patient most likely wore thick glasses or contact lenses to restore vision. If the glasses or contacts cannot be tolerated, sometimes, an intraocular lens can be inserted later. Only your Ophthalmologist can determine if this is feasible.
Post-Operative Care
It is generally agreed that the postoperative period is as important as the surgery itself. This care is usually rendered by the surgeon who operated, but can be done by any competent eye care professional. This shared responsibility needs to be arranged in advance with the consent of all parties. For the period specified by the doctor, the patient should avoid unnecessary strain, should place any medication prescribed as directed, protect the eye with either a shield or glasses and keep the necessary follow-up visits. Any unusual pain, clouded vision, or extreme redness should be reported.
Secondary Membrane or After Cataract
In most cases, when cataracts are removed, the front portion of the capsule of the lens is removed, the contents of the lens is suctioned out, and the back capsule called the posterior capsule is left in place. This is done because it is safer for the retina, and in most cases will help support an intraocular lens implant. The capsule is purposely left intact in spite of the fact that it will often cloud in time. Sometimes this clouding occurs within months of surgery, but in most cases it is within a 3-4 year period. This clouding of the posterior capsule is called secondary membrane or simply an after cataract. It is not exactly a cataract, but it does act in the same manner. When the vision is affected significantly by this membrane, the YAG laser is often used to open a small hole in the center.
Presbyopia
Most people will require reading glasses as they get older. This normal change in the eyes is called presbyopia. It is usually corrected by glasses or contact lenses; however, today there are surgical methods that can reduce or eliminate the need for glasses or contacts. Some of these procedures utilize lasers, or radio waves, but in select patients, multifocal lens implants may be the best choice.
Excimer Laser
A number of procedures are available for the purpose of reducing or eliminating the need for glasses or contacts. This is called refractive surgery. Most people are familiar with Lasik, which is only one method utilizing the excimer laser. With these procedures, the cornea is reshaped. In order to determine if one is a candidate for any of these, various measurements must be taken first. Your Ophthalmologist would then decide which type of surgery would offer the best chance of success.
Radial Keratotomy
Radial Keratotomy is a surgical procedure designed to correct low to moderate amounts of myopia or nearsightedness. By modification in technique, farsightedness and varying degrees of astigmatism, which is an irregular curve to the eye, can also be corrected. By making incisions from the central optic zone out to the periphery of the cornea, the length of the eye is altered and the focusing power is altered. This procedure was developed in Russia and further refined in the United States. Very careful measurements are taken of the thickness of the cornea, the refractive state of the eye, and the size of the central optic zone. Today, RK is rarely done, and has been replaced by other more predictable procedures. However, a variation of RK, called astigmatic keratotomy or limbal relaxing incisions, is performed often during cataract surgery to reduce astigmatism.
Corneal Transplants
The cornea is the clear window in the very front part of the eye. It can be compared to a watch crystal. Sometimes the cornea becomes clouded and impairs vision. There are many causes of this cloudiness. Sometimes it can be congenital, due to disease, or due to trauma. Corneal cloudiness is also seen in patients who have had eye surgery. In many cases, the only treatment is corneal transplant surgery. This involves removing the central part of the cornea and sewing in donated human cornea. Depending upon the condition which caused the clouding, the success rate is most often quite high. It does involve a great deal of surgical expertise to perform, and the postoperative period is long and involved. In the last few years, there have been significant advances in the management of corneal disorders. One exciting technique is called "Decemets' stripping endothelial keratoplasty" or DSEK. This has greatly shortened recovery time.
This area of Ophthalmology is rapidly evolving, getting simpler, safer, and more effective. When this surgery is indicated, it is best to review the current options with your Ophthalmologist.
Laser Surgery
Various lasers are used more and more in all fields of medicine. Particularly with ophthalmology lasers have become extremely important in treatment and prevention of disease. When light shines through certain substances, its energy level is increased. Depending on the substance used, various qualities of laser can be produced. The decision to use a certain laser for a certain problem is determined by the tissue's ability to absorb a particular laser light. The goal is to focus the laser light on the tissue being treated without damaging the portions of the eye that it passes through or the surrounding tissue. Therefore it is important to consider the duration of the laser, the color or type of light, the heat generated, the number of pulses, etc. The types of laser discussed in Eyeline are the Excimer, the YAG and the Argon. These are by no means the only type, but they are the most commonly used at this time.