PRK involves placing a dish shaped ring on the cornea, and filling it with an alcohol like substance to weaken the top layers of the cornea (epithelial layer). This is followed by a sponge like brush to push away the top layer exposing the inner layers. Next, a laser is used to remove (ablate), and reshape the inner layers of the cornea thereby altering the refractive power of the cornea. A post surgical contact lens is placed on the eye to aid the reepithelialization of the cornea (regenerating of cells that were washed away), and maintain patient comfort during this time period. The average time that the patient must wear the lens is 3-7 days.

During this post surgical period, several prescription eye drops are employed to prevent infection, avoid scarring and reduce pain. Our office prefers to use the antibiotic Zymar to prevent infections, and Xibrom, a non steroidal anti-inflammatory agent, to increase patient comfort. In addition, we prescribe FML steroid to reduce swelling and prevent any scarring during the healing process. While the Xibrom helps with the pain, it also slows down the healing so it is only used for approximately 2 days post surgically. The Zymar will be employed until 2-3 days after the contact lens is removed. Finally, the FML will be instilled for approximately 6 weeks after the procedure.

Patients are instructed to return to the office each day while the contact lens is still in the eyes. During that time we expect to see a gradual healing of the surgically induced abrasion. Unfortunately, on occasion, we notice that the abrasion appears to stop healing. If this continues beyond a few days then there is a good chance that there is a physiological reaction to the medications. While they are prescribed to aid the healing process, some times they actually prevent it. In such cases, we remove the contact lenses and either decrease or stop the drug use. We would not stop the medication prior to 3 days post surgically, but if the healing is too slow, we would discontinue their use afterwards, and tell the patient to use copious amounts of viscous lubrication like Celluvisc. By stopping the medications and keeping the eye very moist, it enables the cornea to heal more rapidly.

After the cornea is healed, we may choose to restart the FML if there is any corneal haze, but not before. In short, special care must be used during the healing process to ensure proper corneal regrowth and modify the treatment regimen as required.

Recent studies have discovered that a non prescription nutraceutical called Longevinex which results in high doses of vitamin D delivery in combination with resveratrol which is a strong antioxidant found in the skins of red grapes, plums and other dark-colored fruit helps restore vision in patients with neovascular AMD.

The study was conducted by Dr Stuart Richer in North Chicago, Ill and found that in most patients who suffered from advanced neovascular AMD who did not respond to laser therapy and/or anti-VEGF treatment demonstrated a decrease in scotomas, glare recovery time and improved visual acuity within 3-6 weeks of therapy.

While this treatment modality still requires more study, we should continue to follow our mother’s advice. Eat more fruits and vegetables. Preferably dark-skinned fruit.

Avoidance behavior is a normal reaction when something hurts us, or we are uncomfortable performing an act. Children are not in a position to know or understand that they may have a visual problem that is causing their discomfort. I usually advise a complete eye exam by an Optometrist that is experienced with children and behavioral vision. Unfortunately, well intended parent may take their children to an eye doctor who is not well versed with these visual conditions and may give a clean bill of health to the child. They may see 20/20, but still do not function well under visual stress.

Asthenopia is a condition that describes visual anomalies relating to the visual system, not just the actual eye sight. There is a difference between vision and eye sight. Sight is simply what we see, while vision incorporates sight with how it is interpreted in the brain. So some one may see well, but not function well visually. As with most conditions a problem won’t be found if you don’t look for it.

Frequently found problems with the visual system are Accommodative Infacility (focusing irregularities), Exo or Esophorias ( eye turns), Oculomotor Dysfunctions( eye movement irregularities) and Convergence Insufficiency’s ( inability to turn the eyes in at near to read). Only a complete evaluation of the visual system can uncover these conditions. The symptoms may include double or blurry vision, head aches, difficulty reading due to an inability to follow the line of words smoothly, and poor eye/hand coordination.

Recent studies on Autistic and Hyperactive children have concluded that they may have these conditions secondary to the medications they take for their disorders. Their vision is often 20/20, but they can not function well because of these anomalies. The first step is to diagnose these conditions and the second is to treat them.

The best treatment modality for these visual disorders is Vision Therapy. VT is a therapeutic method that retrains the visual system to function properly. It most often involves working with an eye doctor 2-3 times per week for a period of several months modifying the treatment on a regular basis. While the different conditions must be worked on separately, they are all inter related. Helping one part of the system will affect another. For example, improving the ability to converge will also strengthen the accommodative system. The eye movement will likewise help the eye converge better. All of these will make eye hand coordination better and thus tracking will also improve.

The bottom line is that if a child or adult complains of visual issues despite seeing 20/20, they should be evaluated for these other conditions. Frequently, something else will be found that will improve the situation. Then a “bad” student may become the next star! My wife is a science teacher and she often will find a student that has been given a clean bill of health by their doctor only to be diagnosed later on with an eye condition just described. In addition, hearing should also be tested.

As practitioners we need to think globally in order to give the best possible eye care to our patients.

If it is a medical issue requiring medication, I will prescribe the best pharmaceutical agent to get the fastest remediation of symptoms and at the same time be as safe as possible. As medications change so must my prescribing taking into account the patient’s medical history. Thus, I often laugh to myself when a patient calls me from the drug store asking if there is a “cheaper” medication that will be “just as good.” If there was, wouldn’t I have given that drug to them instead of the one that I did? When I explain that there is “no generic version” or any substitute for that drug I still get comments like ” well how about anything else? or do I really need it anyway?” If some one comes to me and has an infection requiring treatment, the answer is the drug that I prescribed, not ” nothing” or “the drops that her sister once used for a cold sore!” People want my advise so long as it is what they wanted, not what they may need.
I even get patients that feel because they went on line once and read about certain medications that they are now qualified to prescribe drugs for everything from bed sores to HIV. As the saying goes, ” a little knowledge is very dangerous.”

Another favorite of mine is when a patient comes to me with vision or contact lens related complaints asking me to solve their problems. After a comprehensive eye exam I advise them as to what the options are and the best solution for them. Often they can not see well with their contacts or they hurt when they wear them. The simple answer is frequently a better fitting or quality lens. Thus I laugh when I tell them the lens that would solve their problems, but they don’t want to wear that one. They would prefer wearing the one advertised on TV or the lens that their sister in law wore in Tibet!! I like asking them why they came to me if they did not want to follow my advise. Any fool on the street can tell them what they want to hear. If they want an educated, experienced, professional, answer they should be willing to listen and realize that the person they came to knows more then they do about the eyes. I love telling people that they are free to do what they want since it is the American way, and that they can go back “on line” when their eye get worse for the answer.

I am often reminded of the patient who came to me about 10 years ago with a raging eye infection wearing his wife’s 3 year old soft contact lenses. He had a sexually transmitted disease called Chlamydia that caused a massive eye infection. Wearing the contact lenses was like throwing gas on a fire. I told him he needed to throw away that contaminated OLD contacts and start antibiotic treatment right away. He looked at me as though I was telling him to jump off a bridge. He then told me that he did not want to discard the contacts because they were his wife’s and she would be angry with him. Forget about the fact that he contacted a sexually transmitted disease by sleeping with another woman and probably then gave it to his wife. He also refused to take any medication since he only believed in “self” treatment. He then went on to explain that self treatment meant using his own urine that he purified by straining it through his wife’s nylon stockings as an eye drop…..need I say more!!

I made him sign a waiver that I did not condone his treatment and had advised him of a more scientifically tested treatment. I never did find out how he did or if he then gave the disgusting contact lenses back to his wife, but I always use him as a joke when ever I lecture to young doctors.

The point is, that we all seek professional advise from people that are better trained then we are for matters beyond our ability. We should listen to them and while asking questions is a good thing we must remember that we went to them for THEIR opinion. If we are not going to listen to them or go on line while we are still in their office for a different answer or cheaper lens, then don’t waste any one’s time. Doing the right thing often involves taking the advise of people that know more then we do about a condition. Use the Internet as a reference tool not a FREE doctor.

Botulism toxin is a toxic chemical that is produced by a Bacteria. Its purpose is to paralyze the prey thus making it easier to attack, kill and eat it. Before long man in his infinite wisdom came to understand this fact and successfully refined this substance. Early uses included paralyzing ones enemy making it easier to kill him. Poisoning has been a favorite method of treating foes over time and as technology has improved so has Botulism toxin. Medicine has long used herbs and various chemicals to treat disorders and more recently for cosmetic purposes.

The first ocular use for Botulism toxin was to temporarily cure Blepharospasms. These are when the eye lid muscles spasm to the point that the eyes are either constantly blinking or closed due to muscular contractions. The lid injection of the toxin paralyzes the muscles reducing or eliminating the spasms. It lasted approximately 4-6 months at which time another injection was required. In the hands of a highly trained doctor the results are excellent.

The 90’s brought the age of cosmetic surgery and procedures to the forefront. If Botulism toxin stops eye lid spasms why not wrinkles as well. Thus began the ” age of Botox!” The name had to be changed since no normal person would agree to have ” Botulism TOXIN” injected into their face, so BOTOX was born. Essentially it is the same chemical compound that is injected into the facial tissue with the purpose of paralyzing the surrounding area. By relaxing the tissue, wrinkles flatten out and a youthful appearance can be restored. For the most part it is very effective. Unfortunately, where there is money to be made many people perform procedures that they are not well trained in and bad things happen.

When Botox is done by a physician who is familiar with the physiology of the area that is being worked on extra care can be employed to avoid muscle and nerve tissue that may have negative results. For example, if an injection is given too close to the eye itself extra ocular muscles may be affected resulting in eye movement paralysis. This will result in an inability to move the eyes and will cause double vision. In addition, if the injection site is near the eye lids Ptosis or lid droop will result causing one or both eye lids to stay closed all the time. It may also precipitate the lower lid to droop pulling away from the eye. This will permit tears to flow out of the eye and the eyes will be constantly red and very dry. An injection near the Lacrimal Gland will paralyze the tear making gland and extreme dry eyes will result. The good news is that it will wear off in about 6 months. The bad news is that it will wear off in about 6 months. Thus, frequently adjunct medical treatment must be administered to prevent damage to the eye and increase comfort until the affect of the toxin wears off.

Highly trained and experienced Dermatologists and some Ophthalmologists are the best doctors for this procedure. Avoid the doctor who does it as a side line just to make more money. Also ask how many of these procedures the doctor has done and try to find out if there have been any complications resulting from the injection in that office. Always go into this procedure “with both eyes open” and try to keep them that way.

This case scenario is played out many times every month, but should not be ignored if any one experiences these visual disturbances. Vitreous Floaters are small pieces of old retinal tissue that break off of the outer layer of the retina and float around in the jelly of the eye called the Vitreous. In most cases this is a benign condition, but can represent a much more serious condition. These bits of retinal tissue may have come from an area that left a small retinal hole or tear behind and the floater is the result of the tear. In all cases when there are floaters a complete dilated retinal exam must be performed as soon as possible. That is the only way to properly evaluate the retina. When there are flashes of light present as well the level of concern goes up since that may also indicate traction on the retina and can be more serious. If a hole or tear is discovered then usually laser treatment must be done in order to seal the anomaly and prevent further damage.

In some cases vitreous fluid or blood will fill the area where the floater originated resulting in a retinal detachment. This is a much more complicated condition and frequently requires retinal surgery to correct the problem. If left untreated it can result in total blindness in that eye.

Most often, the floaters either dissolve or reattach themselves some where in the eye and are no longer a visual issue. The problem is that over the course of our lives new ones are constantly forming. Thus even if one goes away, a new one is starting. In short, if an individual sees floaters he/she should see the eye doctor as soon as possible to rule out any retinal hole or tear. If there are flashes as well the level of urgency increases. A complete evaluation must include a dilated exam as well.

As the skin folds increase there are pockets of skin that will remain moist and warm and are a good location for bacterial growth. Thus people with Blepharochalasis are more at risk for contracting skin diseases around their eyes. This of course increases the likelihood of an eye infection secondary to the skin disorder. Extra care must be given to ocular hygiene to prevent these issues. Furthermore, as the skin increases in magnitude it typically droops down and may obscure the line of site. This of course will decrease the visual capabilities and affect one’s ability to see either straight ahead, the superior field of vision or both. Thus, there is a medical need to surgically correct this condition. If the visual field is constricted then insurance will cover the surgical procedure since there is a medical necessity. The procedure to correct this condition is called Blepharoplasty.

There are those individuals that feel that they have taken on an aged appearance because of this condition and want cosmetic surgery despite not being bad enough to be covered by insurance. In today’s world of cosmetic surgery this is a fairly common procedure. The street term for this is the “eye job.” Regardless if it is due to age and must be done for medical purposes or just for cosmetic reasons, there are several serious complications that may arise if not done by a qualified surgeon.

Common side affects include having the eyes appear too wide open or too large because too much skin has been removed. This will lead to the eyes drying out and many secondary complications arising from exposure of the cornea. In addition, there can be damage to the tear producing mechanism resulting in a permanent dry eye condition. Red, burning, painful eyes is not a good trade off for looking better. The eyelids may turn inward following surgery causing a constant brushing of the cornea by the eye lashes. This leads to scarring and decreased vision. There may also be damage to the eye lashes themselves if poorly performed.

The bottom line is that when eye lid surgery is performed it should be done by an Oculo-plastic surgeon with a great deal of experience. This will insure a good aesthetic appearance and normal physiological functioning of the eye.

This practice subjects the rabbits to pain and suffering and treats them like disposable tissues. It is a terrible, heartless method that demonstrates a total lack of respect for other living creatures that feel pain and fear as much as we do. Fortunately, there is an alternative method utilizing cow and chicken corneas from dead animals. This procedure has been approved by both the US and Europe. The dead tissues are exposed to the same irritants and studies instead of the live subjects. There is NO pain and NO suffering!

According to Thomas Hartung who is director of the Center for Alternatives to Animal Testing at John’s Hopkins University, the Draize eye test should become history as this and other alternative become available. The germ killing cleaning products no longer have to be tested on live rabbit eyes to see if they are safe.

We as humans have an obligation to safeguard the safety of animals. They are at our mercy and using them for this kind of testing shows a lack of respect for other life. We must employ methods that do not put animals at risk and expose them to pain. Only lab tests should be permitted and when safety and efficacy have been determined then human volunteers can be used. Animal testing never gives us the actual response anyway, so why torture these poor living creatures.

Recent studies have concluded that other factors never before associated with the condition may also be contributing causes to the disease. Certain types of carbohydrates have conclusively been associated with the condition. Specifically, foods rich in carbohydrates that have a high glycemic index have been linked to Macular Degeneration. This factor raises the blood glucose level and is a measure of how fast the carbohydrates are metabolized. The faster the food is broken down the higher the glycemic index.

Foods made from simple carbohydrates like cake and white bread or ones that are sweetened with sugar or corn syrup metabolize very quickly pouring glucose into the system. Complex carbohydrates like fruits and vegetables break down more slowly and result in a steadier release of glucose into the system. Complex carbs are much better for timed release of energy for active people since it keeps fueling the system. It also uses the glucose as it is released thus decreasing the likelihood of having to store it in cells. This of course results in an increase in fatty tissue.

Intake of foods with a high glycemic index causes conditions such as diabetes, hypertension, vascular disease and certain types of cancers. The American Journal of Clinical Nutrition has published studies correlating these foods and conditions. One such study stated that individuals that ate a lot of high glycemic index carbohydrates had as much as a 40 times greater chance of developing macular degeneration and that the severity of the condition would be worse then those that did not eat that class of food.

The theory behind the correlation between the high glycemic index carbohydrates and macular degeneration stems from it’s impact on the smaller blood vessels. High blood glucose like in diabetes weakens the cellular bonds in the blood vessel walls. This in turn weakens the vessel’s ability to maintain good blood flow thought the vessels. As a result the blood leaks out of the blood vessels resulting in damage to the surrounding tissue. In addition, the end organs are not going to get the full supply of blood. It can be compared to a garden hose that leaks water all along the hose. As a result the sprinkler will not get enough water and the grass at the end will turn brown. Also, the areas along the hose will flood damaging those parts as well.

In summation, there are many factors that can contribute to macular degeneration, but recent studies show that simple carbohydrates increase the likelihood of contracting and the severity of the condition. As with most disorders, eating the proper food will keep you healthier and prevent some conditions.

A 25 year old man had LASIK with out incident on a Friday and came in for his first post op visit on Saturday. All was normal as his vision was 20/20 in each eye and aside from a little redness he was fine. He was advised to avoid situations that may result in ocular trauma, rubbing of the eyes or any place that may have windy conditions. He was of course also told to wear his sunglasses outside and sleep with his shield at night.

On Sunday he went to the beach to play in a Volleyball tournament. After fighting off multiple spike attempts, one of them did manage to hit him square in the face resulting in eye trauma. He then fell to the ground landing face first in the sand. On Monday he came in with red, painful eyes and blurry vision. Examination revealed that the flap on the cornea had shifted out of place and there was sand under it. Both of those are emergencies and required bringing him back into surgery to lift the flap and clean under it. He was seen on Tuesday and he was not as happy as the first post op visit. He had more redness, discomfort and his vision was only 20/40. He had to use the steroid drops for 2 weeks until the swelling resolved and his vision returned to 20/20. He was very fortunate that the problem that he caused was able to be corrected. Had the flap been completely taken off during the volley ball game or a lot of sand got under the flap, the results could have been devastating. He ultimately did achieve 20/20 in each eye and was happy with the results. He did have more glare then the average patient because the juncture where the flap was made scarred a little resulting in diffraction of light. It will fade over time, but may not completely resolve itself.

The second patient was 100% compliant, but had bad luck. She was a 38 year old woman who underwent LASIK and was perfect for the first week following surgery. She returned 10 days after the procedure complaining of pain, decreased vision and redness in both eyes. An examination revealed both flaps were milky white and the edges were slightly lifted up. She stated that she was avoiding all the things that she was supposed to and even visited her ailing friend in the hospital. The significance of the hospital visit is that she had apparently been exposed to an infectious agent that was attacking the corneal flaps. There was no additional surgery required, but aggressive medical treatment was needed. She was put on several very strong antibiotic eye drops, steroids and even an oral antibiotic to kill the infectious agent. She was followed up on a daily basis and after 1 week she began to show signs of improvement. The corneal flaps did reattach at the edges and became almost perfectly clear. Her best vision was 20/25- in each eye and her eyes were healthy.

The first patient was foolish and caused his problem, the second did nothing wrong, but had bad luck. The bottom line is that when undergoing refractive surgery one must always do as instructed, and hope for the best with factors that can not be controlled.