Seeing Our Way To A Clearer Future

Posted in Cataract, Clear Lens Exchange, Glaucoma, Premium IOLs, Presbyopia

Vision is considered to be the most valuable and informative of our senses. Excellent vision and healthy eyes don’t just happen by chance, but are dependent upon so many factors, many of which we each have significant control over. While we have no influence over any genetic predisposition, everything else is fair game. This discussion will look at all of the factors that we can manipulate.

We will not only cover ways to prevent loss of vision but how to most comfortably use our eyes on a daily basis. There are many areas to cover, from numerous eye conditions, frequency of eye exams, lifestyle and nutritional factors to ergonomics and lighting.

First let’s review a number of eye conditions and how they might impact our daily activities.

• REFRACTIVE ERRORS: This is basically a fancy term for needing some type of optical correction (glasses or contact lenses) to see clearly. Variations include nearsightedness (myopia), farsightedness (hyperopia), astigmatism (a mix of near & far-sightedness) and presbyopia (the loss of near vision focus as we have birthdays). Glasses or contact lenses can correct the refractive errors so that we can see clearly, with everything in focus. Typically, when we are younger, single vision lenses do the job, but as we lose our near focus later in life, we require reading glasses or bifocals (which are most frequently nowadays progressive no-line lenses). We will discuss more of this when we cover computer vision issues and protection from harmful ultraviolet light rays. Also, new technology allows us to correct refractive errors via refractive surgery (for example, LASIK) and clear lens exchange (implanting an intraocular lens after removal of the eye’s natural lens).
• CATARACTS: The natural lens in the eye becomes clouded and reduces our vision over time. One of the few things guaranteed in life is: if we all live long enough, we will get cataracts. They are a by-product of birthdays. The three vision concerns we worry about as we have birthdays, other than needing glasses, are cataracts, glaucoma & macular degeneration. The prevalence of Macular Degeneration is 1.5% for the US population over the age of 40; for Glaucoma the prevalence is around 2% and for cataracts it is significantly higher, reaching levels around 50% by age 80.

Simply put, when we are born the natural lens in the eye is crystal clear and as we age it gets cloudy, showing signs of early lens changes by the time more of us reach our 50’s. A cataract is the clouding of the natural lens which, ultimately, blocks light from getting properly focused on the back of the eye (the retina).

As the cataract worsens it affects both the quality & quantity of our vision. For example, if we go to renew our driver’s license in Maryland, we need corrected (that’s with glasses or contact lenses) vision of 20/40 or better to drive at all times. A cataract will frequently reduce the quantitative measurement below the 20/40 level. However, before that ever happens there are many qualitative effects of the beginning of a cataract.

Daily tasks like reading become more challenging, requiring brighter room lighting than ever before. The contrast of the newspaper seems to get worse every month. Contrast in general gets less and less discernable especially at night. Driving into the rising or setting sun becomes extremely difficult. Glare becomes more of an issue. Those bright halogen headlights and bright streetlights are extremely uncomfortable. All of this is due to light entering the eye and scattering throughout the back of the eye as it hits the cloudy natural lens.

At this point in time, the only remedy is cataract surgery which has become one of the most frequently provided elective surgical procedures in the US (over 3.5 million per year) and one with the fewest complications. The clouded natural lens is surgically removed through a very small incision and replaced with an artificial intraocular lens (IOL). Each IOL has a specific prescription selected for each patient with the typical goal being the best possible distance vision without glasses. Reading glasses for up close are then needed but the quality of vision is dramatically improved.

There are IOLs now available that can correct astigmatism that you may have had all your life. Also, Multifocal and Accommodating IOLs are available that can provide BOTH distance and near vision without having to rely on reading glasses.

The actual surgery is typically performed in an out-patient surgical facility and you are usually home in time for lunch and enjoying clear and crisp improved vision within days. A common myth is that cataract surgery is performed with a laser. Even today, with “laser assisted” cataract surgery, this myth is false. There are eye drops required before and after surgery to ensure the very best results and you are usually back to your (new and improved) daily routine within just a few days. Of course, everyone responds and heals differently, so expect some variations to the healing process.

We often wonder about how one might prevent cataracts. Studies show that if we take steps early in life we may be able to delay the onset of visually disabling cataracts but we can never truly prevent them. Delaying the onset includes protection from ultraviolet light (proper quality sunglasses and hats with brims), possible a baby aspirin and certain anti-oxidants though the jury is still out and, just recently, a new study showing a lower incidence of cataracts amongst those on a strict vegetarian or vegan diet. It is estimated that 435,000 Marylanders suffer from cataracts.

• GLAUCOMA: The eye transmits the information we need to see via the optic nerve to the brain. Glaucoma causes damage to nerve cells that make up the optic nerve resulting in irreversible damage and loss of vision. Usually, the damage and visual loss occur slowly, without warning and without pain or discomfort which is why it is so critical that everyone over the age of 50 has an annual eye exam.

Approximately 2% of the US population over the age of 40 have glaucoma; many are totally unaware. Fortunately, when detected early enough glaucoma can be controlled and subsequent vision loss can be halted. A variety of treatments exist including eye drops, laser treatment and surgery. While there is nothing that can be done to prevent glaucoma from developing, increased risk factors include age, race (African American & Hispanic populations have a higher prevalence), diabetes, eye trauma and long term use of steroid medications.

It is estimated that 58,000 people in Maryland have glaucoma.

• MACULAR DEGENERATION: Age-related macular degeneration, often called AMD or ARMD, is the leading cause of irreversible vision loss among people who are age 60 and older. It is estimated that 10 million people will experience this age-related visual impairment during their retirement years.

Macular degeneration is a disorder of the central retina, the light-sensitive inner lining of the back of the eye. The macula is a small central portion of the retina which is necessary for sharp “straight ahead” vision needed for reading, driving, or recognizing faces. Macular degeneration does not cause total blindness because the remaining and undamaged parts of the retina around the macular continue to provide peripheral vision.

There are two types of age-related macular degeneration: Dry AMD, which accounts for 80% of all cases of AMD, but only 20% of severe vision loss, and Wet AMD, which occurs in the other 20% of cases, and causes the majority of severe vision loss. AMD almost always invades both eyes and a combination of Wet AMD in one eye and Dry AMD in the other eye is common.

Dry AMD is an early stage of the disorder of the disorder and may result from aging and thinning of macula tissue, deposits of pigment in the macular, or a combination of the two processes. Dry AMD is diagnosed when yellowish spots known as drusen begin to accumulate in and around the macula. It is believed that these spots are deposits of debris from deteriorating tissue and gradual central vision loss may occur. Through a period of years, slow progression to late-stage geographic atrophy can occur where degeneration of retinal cells can cause severe vision loss.

With Wet AMD, new abnormal blood vessels (choroidal neovascularization) grow beneath the retina and leak blood and fluid. This leakage leaves permanent damage to light-sensitive retinal cells, which die off and create blind spots in the central vision. Eventually, if left untreated the process creates scarring (subretinal fibrosis) and severe vision loss.

Risk factors for macular degeneration include but are not limited to: Age, people age 60 years and older; Hereditary, AMD runs in the family; Smoking; and Hypertension or high blood pressure.

At Katzen Eye Group, Drs. Michael Grodin and JB Harlan use the most cutting-edge technology and equipment to diagnose AMD. Our philosophy is simple; we are here to use every possible tool to prevent AMD from stealing a person’s vision and independence. These tools include Fluorescein Angiography, a test in which a Doctor injects a vegetable based dye into a vein and photograph the retina (macula) and then observe the blood supply to the retina (macula), as well as Optical Coherence Tomography which takes cross-sectional scans of the various layers of the retina.

There is yet no outright cure for AMD, but some treatments may delay its progress or most recently improve vision. Treatments for AMD depend on whether the disorder is in its early-stage, Dry form, or in the more advanced, Wet Form.

No FDA-approved treatments are available for Dry AMD, although a few are now in clinical trials. A National Eye Institute Study called Age-Related Eye Disease Study (AREDS) has produced strong evidence that certain nutrients such as beta carotene (Vitamin A), Vitamin C and E, Lutein, and Omega-3 fatty acids may help prevent or slow progression of Dry AMD. These findings have led to the development of a number of different AREDS Vitamin formulas for macular degeneration prevention. The AREDS study shows that taking high dose formulas of certain supplements found in eye vitamins may reduce the risk of early to moderate AMD progression by as much as 25%.

In the Wet type of AMD, Anti-Vascular Endothelial Growth Factor (VEGF) drugs such as Ranibizumab (Lucentis), Bevacizumab (Avastin), or Aflibercept (Eylea) can be injected into the eye to cause the abnormal leaking blood vessels to stop bleeding or leaking. These injections have revolutionized the treatment paradigm for AMD and need to be repeated every month for an unknown duration with the intention of not only stopping the loss of central vision, but up to 30% of patients can have a regain in reading vision.

It is important to remember that no two people with AMD are the same and that AMD changes with time in everyone. Therefore, treatment must be continually evaluated and individualized to the situation at hand.

The Amsler Grid (see figure below) is used to screen for Macular Degeneration. The test involves looking at a square grid with a dot in the center. The grid should be held 12 inches away from the face, wearing reading eye glasses. Cover one eye at a time and star at the dot in the center of the grid. If there appears to be any holes or blurry spots, or lines look wavy, fuzzy, crooked, distorted, or broken, there could be the possibility of AMD and phone call to an eye care specialist should be made.

• DIABETIC RETINOPATHY: The American Diabetic Association (ADA) defines diabetes as a Glycosylated Hemoglobin (A1C) greater than 6.5%, a Random Blood Sugar of 200 mg/dl or higher, or a Fasting Blood Sugar of greater than 26 mg/dl.

Diabetes can affect the eye in many ways. The most common manifestation is Diabetic Retinopathy. There are two stages of Diabetic Retinopathy. In the first, called NonProliferative, the main concern is Macular Edema. This occurs when blood vessels start to leak either fluid or protein material called lipids that can result in blurry central vision. it is usually treated with either laser or medications injected into the eye.

In the other stage called Proliferative Diabetic Retinopathy, abnormal blood vessels called neovascularization start to grow and can lead to the eye filling with blood (vitreous hemorrhage), scar tissue (preretinal fibrovascular tissue), and retinal detachment. Depending on the severity of these could be treated with either laser or retinal surgery. Overwhelming evidence shows the better the blood sugar levels are controlled, the less risk of developing Diabetic Retinopathy and its complications.

For anyone diagnosed with Diabetes it is critical to have an annual eye examination that includes dilation of the pupils so your eye doctor can determine if any early signs of Diabetic Retinopathy exist. The earlier signs are detected and treated the better the prognosis for good vision.

• DRY EYE SYNDROME: (DES, also known as Keratitis Sicca) is a condition that affects over 60 million Americans and is the leading cause of ocular discomfort. Symptoms are quite varied by frequently include:
• Feeling of drying and discomfort
• Itching and Burning of the eyes or a sandy/foreign body sensation
• Blurred Vision, especially when reading or at a computer
• Pain upon opening eyes after sleeping
• Contact Lens discomfort and intolerance

Those most susceptible to DES symptoms include people with the following risk factors:

• Rheumatoid arthritis or Thyroid disease
• Use of medications such as antihistamines, blood pressure medications, decongestants, anti-depressants or hormone replacement therapies
• Working in a dry environment or with closed air circulation (for example, hospitals, airplanes)
• Daily regular computer use (we blink less frequently when viewing a computer)
• Birthdays (also referred to as Aging)
• History of previous trauma to the eyelids

There are a variety of tests that are performed during your eye exam to help determine what degree of Dry Eye Syndrome you have, which will help your doctor formulate the best strategy to lessen the discomfort from chronic DES.

Some of the possible treatment methods include:

• Identify & eliminate environmental factors (for example, adding a humidifier during the dry winter months or turning off the ceiling fan)
• Artificial tear supplements, anti-inflammatory eye drops
• Punctal occlusion or IPL laser treatment
• Adjusting medications, when safe to do so
• Nutritional supplements omega-3 fatty acids to improve quality of tear film

• COMPUTER VISION: Our eyes and our vision are put to the test pretty much every day as the way we read and obtain information has changed so dramatically. Today we the bulk of our reading viewing computer monitors, e-readers, iPads and smart phones. While studies have demonstrated no permanent harm is done to the eyes, temporary discomfort can be extremely annoying.

Computer Vision Syndrome (CVS) affects some 90% of the people who spend three or more hours a day at a computer. The symptoms include:

• Headaches, Blurred Vision, Neck pain
• Redness of the Eyes, Fatigue
• Eyestrain, Dry irritated eyes
• Double vision, Difficulty refocusing the eyes

The causes of these symptoms include poor lighting, glare, improper viewing distances, poor posture, uncorrected vision problems and many environmental issues such as air circulation and humidity.

To minimize the ocular discomfort from reading an electronic display the 20/20/20 rule is helpful. Every 20 minutes focus the eyes on an object at least 20 feet away for 20 seconds. Additionally, studies have shown that we blink less frequently when viewing a computer monitor so remember to blink your eyes on a regular basis which will help to maintain proper lubrication for the cornea.

It is extremely important to wear a proper spectacle correction that relaxes the eyes’ focusing, reduces glare and helps maintain some humidity or moisture around the eyes.

•  MAXIMIZING EYE HEALTH: We can summarize with the following list that will help maximize eye health over a lifetime:

1. Always wear Ultraviolet protective eyewear outdoors
2. Obtain a complete eye exam from your eye doctor every year once over the age of 50
3. Maintain a healthy lifestyle of exercise and diet
4. Include in your diet fruits and vegetables those that are the most colorful – red, dark green, orange or yellow.
5. Include in your diet fatty fish such as salmon, tuna or mackerel 2-3 times per week as well as servings of nuts
6. Avoid high fat, high cholesterol food which can hamper blood flow.
7. Do not smoke and avoid smoky environments
8. Take a daily vitamin that includes antioxidants and zinc which have been found in National Eye Institute studies to help slow or prevent the development of macular degeneration. Your eye doctor can help recommend the best formula for you.
9. Always wear eye protection when working around potential projectiles (lawn work, wood work, etc.)
10. Avoid hazards such as fireworks