The Importance of Vision

Did you know that approximately 75% of all neurons in your brain have to do with vision or processing visual input? The eyes help answer certain questions about the environment: who? what? where? howbig? is there movement? how fast? relative position? The following TED talk has an overview of vision in knowledge formation.

Cataract Surgery and New Tech Lens Implants

Newer high tech lenses are starting to be available for use in restoring vision after cataract surgery. Previous models were all monofocal, giving clear vision only at one distance. There are now several bifocal lenses approved for implantation. Rezoom, Restore, and Crystal lenses are all available to the patient, but because Medicare won't pay for the new lenses the patient will have to pay several hundred dollars more for these lenses. Why is this important? Some seniors in the 7th decade and up are forever losing their reading glasses and bifocal lenses would lessen their need for a reading glass. There are also astigmatic lenses which will compensate for corneal toricity that causes defocus of the retinal image. Wavefront technology is being used to optimize focus in some new lenses and the bar is gradually being raised with respect to the best choice for your cataract surgery . There are some tough choices to be made and you must be counseled by your surgeon on the best path to take. Post op follow up may be done by your surgeon or the referring optometrist as the insurance companies direct. This is one of the most successful surgeries ever and there are very few instances in which waiting til the last minute is a good idea. In fact, waiting to let the human lens become extremely mature may complicate your surgery. We are glad to answer questions you may have and look forward to providing you with better vision.

Regenerative Medicine

I frequently get questions from visually disabled patients or their families about regrowing functional units or whole body parts and when will this be possible? The following talk on ted.com is very interesting and points the way to a future technology that we all have wondered about. The Japanese have alocated large amounts of money to pursue this technology. The human foetus below a certain aqe has the ability to regenerate a limb...this power is lost at time goes on. Dr Russell shows a film in which a 78 year old man regenerates his fingertip! Stem cells are the key to this and sadly have been neglected by the NIH and the Bush administration. As healthcare becomes more expensive it seems that it may be more cost effective to regenerate function rather than amputate dysfunctional parts and deal with the consequences. New directions are clearly needed, but this requires leadership with a vision for the future. Ted.com has many interesting talks , but I found this one by Dr Russell to be most interesting and I hope you do too.


Ray Kurzweil is also a tech guru who foresees great changes in the next decade...."The Singularity Is Near" is the title of his book about the exponential growth of biotechnology and the re-engineering of the human condition.

ACANTHAMOEBA KERATITIS (YOU DON'T WANT IT!)

A recent issue of Review of Optometry gave a rundown of the latest thinking on this devastating corneal infection. Thankfully we don't see many of these problems, but the CDC has in the past alerted the medical professions to peaks of incidence. You no doubt heard about this in the press and it seems that in late May of 2007 the FDA notified another contact lens solution manufacturer (AMO) that there had been in increase in incidence in patients using Moisture Plus multi purpose contact solution. Acanthamoeba is a ubiquitous organism, but reports were not seen in the literature until the 70's and then a peak of cases in contact wearers in the mid 80's. Treatment was very unsuccessful at first and remains difficult today. There didn't seem to be a magic bullet for this critter. It can get under the contact lens and feeds on whatever it finds...including your cornea. It can encyst and remain dormant for a time and then come back to cause problems. This is why doctors preach "no tap water" on your lenses and" discard your case frequently....follow cleaning directions and use fresh solution each night. "

With the Moisture Plus recall there may be an issue with propylene glycol an ingredient used to soothe and wet the eye. This is also used in tear solutions sold over the counter and may be sold for use on contacts. It is currently our advice for extended wear contact wearers not to use a solution that contains propylene glycol. This chemical seems to encourage encystation of the amoeba. Encysted forms are very resistant to treatment. Tap water is a big source of both fusarium fungal infections (~80% of the fusarium outbreak used tap water on their lens) and amoeba infections also. The FDA has not finished it's investigation and has not issued any guidance on lens materials as of March,2008. The best protection is follow instructions to the letter. Extended wear is of course more of a general risk for eye infections. Forget the labeling that stated "no-rub"....rubbing and rinsing is now viewed as critical to getting your lens clean.

CONTROVERSIAL NEW APPROACH TO DIABETES

The following is an abstract from a journal article that is sure to stir some controversy in diabetes treatment. For years docs have been telling patients to lose weight and get exercise to help control diabetes and of course this is easier said than done for some patients. It will be interesting to see if this approach is useful:


Physician's First Watch for January 23, 2008David G. Fairchild, MD, MPH, Editor-in-Chief
Gastric Banding Brings Remission in Type 2 Diabetes

Gastric Banding Brings Remission in Type 2 Diabetes
Gastric banding far outperforms conventional therapy in achieving remission of type 2 diabetes, according to an industry-sponsored, preliminary study in JAMA.
Australian researchers randomized 60 obese patients (BMIs between 30 and 40) with type 2 diabetes to laparoscopic adjustable gastric banding or "best practice" conventional therapy. When assessed 2 years later, 73% of the surgical group had achieved remission versus 13% of the conventional-therapy group. Likewise, weight loss averaged 20% of baseline with surgery and 1.4% with conventional therapy.
Editorialists, citing the Australian surgical team's high level of experience, say "their excellent results may not be ... reproducible elsewhere." And they acknowledge that the "general applicability of these findings remains to be determined." Nonetheless, they observe that guidelines for diabetes care "do not mention surgery at all, even for severely obese patients." They urge professional societies and clinicians to "reconsider the role of surgery to treat diabetes."
JAMA article (Free abstract; full text requires subscription)

CONTACT LENS PROBLEMS? MOST CAN BE RESOLVED

The last several years has been interesting for those of us in contact lens practice. There have been a few recalls of contact lens solutions and lens recalls as well. B&L's problems with Renu were well publicized, but other companies also had recalls. The following is an excerpt from a contact lens journal article : Patient compliance has been suggested as a factor in the recent outbreaks of Fusarium and Acanthamoeba infections. We compared the data generated on compliance by Collins and Carney1 in 1986 in Australia to a study reported at BCLA in 20072. When we look at these two studies we find some very interesting comparisons. First, washing hands, while an important step in hygiene, does not remove all organisms and is not performed by all patients. Collins and Carney reported that this behavior was correlated with the observation of corneal staining. The 2007 study indicated that 35% of patients surveyed admitted to irregular hand washing before lens handling. The 1986 study indicated that about 18% of patients irregularly changed their solution which leads to corneal staining and increased deposits. The 2007 study similarly reported 15%. A new survey by the Contact Lens Council3 indicates that as many as 44% of patients occasionally “top off” solutions. Lens case care continues to be equally dismal. Collins and Carney reported about 28% did not clean lens cases, which significantly correlated with corneal staining. The 2007 BCLA poster reported that 38.7% of patients clean lens cases less than once a week. In the BCLA poster, 58% of patients use tap water to clean their case, probably a primary source of Pseudomonas bacteria and other organisms. The recent Contact Lens Council survey reports 54% of patients don’t clean lens cases after every use.Poor compliance in lens handling, lens case hygiene, and “topping off” have not improved since the 1980’s leading to the question of what are we doing as medical professionals to educate patients. These major sources of non compliance affect our patients’ exposure to microorganisms. As reported at BCLA, we are spending only 1-3 minutes with patients to reinforce lens care and only when the patient shows some behavior that indicates non-compliance.
If we are to improve compliance, we need to start with teaching and reinforcing correct lens care to our patients.References:1. M.J. Collins L.G. Carney, Compliance with care and maintenance procedures amongst contact lens wearers, Clinical and Experimental Optometry 69(5): 174-177; 1986.2. R.P.Stone, The Importance of Compliance: Focusing on the Key Steps, Poster at BCLA Annual Meeting 2007.3. Contact Lens Council Survey as reported in Contact Lens Today August 19, 2007



There have also been hints that showering in contacts can be a factor especially in light of the fact that some municipal water suppliers have changed the way they purify water. Last year it was also found that Legionaires disease bacteria (legionella) can be found in water coming from your tap. Contact lens wearers should never put tap water on their lenses or in their cases....cases should be discarded frequently (every month or 2 is good)...don't buy solutions in huge containers that will sit opened for months at a time....it is better to buy smaller units and use them before the preservatives go flat. It is important to let your case air dry without the cap on during the day while the lens is being worn. This helps keep down case contamination.



I still feel that the majority of contact lens intolerance cases I see are allergy related. Giant papillary conjunctivitis is an allergic lid phenomenon that can exist without the conventional allergic symptoms of sneezing or sinus congestion...just itching, foreign body sensation and contact lens intolerance. Some wearers need to use oral and topical drugs to make it through the allergy season and maintain a good level of comfort. Sometimes a break in wear is necessary, but we can usually get you back in lenses within a month or two. It is our job to advise you on contact lens safety and how you can avoid these complications. Please check this website frequently for any news on contact lens recalls or new products that might be of interest. One of the latest contacts to come out is a toric bifocal lens from Cooper. I have seen some success with this new lens and look forward to using it . We have been waiting for advances in this product category for some time. The outlook for 2008 is much better for the contact lens marketplace. The recalls of the past years have refocused us on safety and better communications to new wearers. The wearer has a lot of control and responsibility to follow instructions for safe wear. We take our responsibilities to you, the wearer, seriously. All extended wear patients should come back for followup on a regular basis...this is a mandated schedule of followup. If patients disregard this regularly we may have to withdraw our OK for continued wear. This is usually for limbal neovascularization and or stem cell depletion and loss of clarity in a normally clear tissue. It is possible to physically damage your cornea and your vision by neglectful habits and poor followup. The good news is that the newer silicone hydrogel lenses provide 4-5 times the oxygen supply to your cornea as compared to the older style lenses. In our view, if you are sleeping in lenses you should be in a silicone hydrogel.

Choosing Eyewear

Choosing eyewear can be a frustrating and challenging job. This is often made more difficult if the eyecare staff is inexperienced or even worse if they are on commision to sell expensive extras. Then you may not be able to trust the advice you get. Let's face it! Some people are more difficult to fit than others. The final cosmetic result you achieve with your choices will be with you daily for the next year or so. All the more reason to seek out reputable sources who have the experience to make helpful suggestions and share their product knowledge. Today's optical goods are thinner, lighter and better looking than what we had previously. High index lenses help us fashion a thinner lighter pair of lenses so that even those with high prescriptions can enjoy a reasonable and fashionable result. Anti-reflective coatings help pass more light through the lenses and help hide the annoying reflections that hide your eyes from observers. Does everyone need A-R coatings?...no! Even though these coatings are now tougher than they have ever been I would not advise people who work in dusty or challenging environments to wear them. Maybe they should be used only on dress glasses for those working under less than ideal conditions. If you are a person who does a lot of night driving these coatings are great and can significantly improve your night vision. For people who are rough on frames or have corrosion problems with their eyewear, the obvious choice is a titanium frame or perhaps a zyl or composite frame. There are a dizzying array of choices to be made and we will try to help you with making the best choice for you and your lifestyle. In general frames have tended to be smaller and metal frames have been more popular. Fashion is cyclical and now we may see some designers going for more color and effects only achieved with plastics.

FDA Lasik Data

The web is a wonderful source of information and misinformation. When considering something as serious as lasik patients should make every attempt to check and cross check the facts concerning their vision and their proposed procedure. The FDA has made available a lot of data on the individual lasers and the data used to make the decisions on approval for marketing in this country. The following is an excerpt from their website meant to help patients in their decision.
When is LASIK not for me?

You are probably NOT a good candidate for refractive surgery if:

• You are not a risk taker. Certain complications are unavoidable in a percentage of patients, and there are no long-term data available for current procedures.

• It will jeopardize your career. Some jobs prohibit certain refractive procedures. Be sure to check with your employer/professional society/military service before undergoing any procedure.

• Cost is an issue. Most medical insurance will not pay for refractive surgery. Although the cost is coming down, it is still significant.

• You required a change in your contact lens or glasses prescription in the past year. This is called refractive instability. Patients who are:

• In their early 20s or younger,
• Whose hormones are fluctuating due to disease such as diabetes,
• Who are pregnant or breastfeeding, or
• Who are taking medications that may cause fluctuations in vision,

are more likely to have refractive instability and should discuss the possible additional risks with their doctor.

• You have a disease or are on medications that may affect wound healing. Certain conditions, such as autoimmune diseases (e.g., lupus, rheumatoid arthritis), immunodeficiency states (e.g., HIV) and diabetes, and some medications (e.g., retinoic acid and steroids) may prevent proper healing after a refractive procedure.

• You actively participate in contact sports. You participate in boxing, wrestling, martial arts or other activities in which blows to the face and eyes are a normal occurrence.

• You are not an adult. Currently, no lasers are approved for LASIK on persons under the age of 18.

Precautions
The safety and effectiveness of refractive procedures has not been determined in patients with some diseases. Discuss with your doctor if you have a history of any of the following:

• Herpes simplex or Herpes zoster (shingles) involving the eye area.

• Glaucoma, glaucoma suspect, or ocular hypertension.

• Eye diseases, such as uveitis/iritis (inflammations of the eye)

• Eye injuries or previous eye surgeries.

• Keratoconus

Other Risk Factors
Your doctor should screen you for the following conditions or indicators of risk:

• Blepharitis. Inflammation of the eyelids with crusting of the eyelashes, that may increase the risk of infection or inflammation of the cornea after LASIK.
  
• Large pupils. Make sure this evaluation is done in a dark room. Younger patients and patients on certain medications may be prone to having large pupils under dim lighting conditions. This can cause symptoms such as glare, halos, starbursts, and ghost images (double vision) after surgery. In some patients these symptoms may be debilitating. For example, a patient may no longer be able to drive a car at night or in certain weather conditions, such as fog.

• Thin Corneas. The cornea is the thin clear covering of the eye that is over the iris, the colored part of the eye. Most refractive procedures change the eye’s focusing power by reshaping the cornea (for example, by removing tissue). Performing a refractive procedure on a cornea that is too thin may result in blinding complications.

• Previous refractive surgery (e.g., RK, PRK, LASIK). Additional refractive surgery may not be recommended. The decision to have additional refractive surgery must be made in consultation with your doctor after careful consideration of your unique situation.

• Dry Eyes. LASIK surgery tends to aggravate this condition.

It is helpful for you to know how long the healing period should last and what to expect. With larger corrections the healing will be slower. Your doctor is the best source of this information.

Reversing Coral Reef Damage

The February 2007 issue of Biophontonics International has an interesting article about Australian researchers and the role that several fish species can play in reversing coral reef damage. It seems that the dusky batfish and the orbiculate batfish are the greatest consumers of microalgal blooms that can slowly choke coral reefs to death. They can function as cleaners of the reef ecosystem. In the Dec 19th issue of Current Biology, Bellwood et al describe these fish as assuming this alternate role under exceptional circumstances and point out that this species has no protection status and faces increased human encroachment. The dugong and the green turtle are also consumers of algae that have been under great pressure from humankind. Researchers are rushing to find out what factors help to heal the reef and hopefully aid in protecting this delicate balance. Offshore in Pensacola we have the Oriskany naval vessel that was sunk as an artificial reef. Programs of this kind are great for the local economy: fishing, diving and tourism in general. What doesn't work well seems to be the old idea of sinking old auto tires as reefs. Where this has been tried, the tires seem to work loose and wash up on beaches after leaking toxins into the water. So we learn from mistakes. Florida has been slow in permitting reefs compared to Alabama despite the efforts of sportfisherman and other interested parties. In the vein of the maxim "think globally and act locally" I would direct anyone interested in preserving Gulf of Mexico waters estuaries and rivers to this website www.healthygulf.org.
There are many topics to discuss from wetlands to Corps of Engineers projects to natural gas projects in the gulf and how to best avoid further habitat destruction.

Deal or no Deal? Optical Choices

Yeah Doc, I got my frames 2 years ago at "Adequate optical" down the street, but the lenses scratched so I went to "Three Weeks Later" optical and had new lenses put in but they don't seem right to me. I need a new frame by now since the earpieces are corroded. "Brown Bananna " optical had some closeouts and discontinued merchandise for very reasonable prices, but they were not too fashionable...know what I mean? Just some stale inventory I guess. What can I do?
In desperation I tried "Not Licensed In My State" optical over the internet and found the frames I wanted but they rub my nose and fall off my face everytime I bend over. Also the coatings are scratching off the surface of the lens. I called about it but they said I had no warrantee. What can I do?
In our industry we hear a never- ending litany of complaints such as these. Quality comes at a price as does service. Value has to be judged on a balance of price, quality and service. If you leave one of these factors out in your decision making you will likely be disappointed. Lots of folks buy discontinued frames thinking they are a bargain, but then discover that they can't get replacement parts or replacement frames to match their lenses. Obviously they didn't understand this when they got that "great deal". Caveat emptor....

Demographics of Aging Vision

Sobering statistics about vison loss in the over 40 age group give us plenty of cause to take precautions and have routine exams on a frequent basis. A recent article ( Arch Ophthalmol. 2006;124:1754-1760) estimates the cost to the US for vision conditions in this age group could approach 35.4 billion dollars per year in direct and indirect costs. This counts lost productivity and underemployment figures. Direct cost from visual conditions is 16.2 billion in medical costs per year. Much of this is preventable. If a diabetic puts off seeing the eye doc for years and neglects his sugar control, this is a recipe for eventual disability. Uncontrolled hypertension and thyroid problems can also lead to severe visual deficits. As in so many other areas an ounce of prevention is worth a pound of cure and you are in control of this. Only you can pick up the phone and make the appointment. National Eye Institute figures indicate that at 40 there are 0.3% of the population with visual impairment . This figure climbs to 23.7% at age 80. In the fourth decade 2.5% of us will have cataracts and in the eighth, 68.3%. Severe age related macular degeneration ranges from 0.1% at 40 to 11.8% at 80. Intermediate or less severe ARMD starts with 2% at 40 and goes to 23.6% at 80. So you see that few of us will escape having some sort of visual complication in our lives. A full set of statistics is available at the NEI website: http://www.nei.nih.gov/
From the American Journal of Ophthalmology comes the study indicating that for every dollar spent on prevention and close followup, five dollars of value is returned to society. Said differently, the burden of blindness upon society is lessened greatly if we maximize our efforts at prevention and frequent exams.

I See 20/20 So Nothing's Wrong!

This is the number one mistake not to make. Don't assume that because your central vision seems sharp and crisp that you couldn't have hidden problems. Many retinal problems go undetected for years before they become apparent to the patient. For instance in the picture you can see that this patient has had serious retinal complications in his superior retina...but not in the macula (darker area to the right of the optic nerve). His superior retina is involved so we would expect an inferior field defect. Because the macula is not involved his vision straight ahead is still good. Perhaps the number two mistake that older folks make is that their vision seems to be getting better so they gladly put off coming in to the eyedoc's office. This is sometimes termed "second sight". Diabetes or cataracts or corneal swelling could be responsible for the changes that they are noticing. Big changes in the over 50 crowd are not a good sign. There is no pain in the retina or optic nerve so any pathology can cause painless progressive blindness. There is no substitute for regular comprehensive eye exams.

Will the Real Harry Potter Please Stand Up?

http://www.physics.usyd.edu.au/cudos/research/plasmon.html
Just as Jules Verne's fiction predicted space and undersea travel and was realized by scientific and technological advances, today's scientists are stretching to achieve new capabilities that will match or exceed recent fiction. Writers have proposed cloaking devices and invisibility as a tactic for many years...remember the Klingons? Now if you think optics is a boring subject you must read about these developments. Check out the latest in superlenses...cloaking devices may be right around the corner. Nanotechnology may make it possible to bend visible light to create new optical effects. Super sharp pictures, increased resolution beyond presently accepted limits and the ability to see through or around obstacles may all be achievable. In addition to the group at Sydney, Duke University researchers are also experimenting with metamaterials and are working in the microwave spectrum and ultimately the visible spectrum as well. The ability to hide obstructions that block line of sight microwave transmissions may be the first real application to evolve. Needless to say the military is very interested and funding for this research should not be hard to come by. The Milton-Nicorovici hypothesis is the mathematical underpinning of work on the superlens. Essentially a thin film of silver can have a negative index of refraction that will bend light in an unnatural way...negative indices of refraction have only recently been achieved. I am sure there will be many surprising outcomes from this research. Other optical/laser researchers are working on novel propulsion systems at White Sands New Mexico. The lightcraft runs on nothing but laser light and air which is combustable at high temperatures. http://www.cnn.com/SPECIALS/cold.war/experience/the.bomb/route/04.white.sands/

Real Advances in Retinal Treatments

Age related macular degeneration(abbreviated ARMD or sometimes AMD) is a slowly progressive condition that is the most common cause of blindness in the 65 and over population. In the fifth decade there is a 2% chance of having signs of macular degeneration. In the ages 65-75 there is a 10% chance and for 75-85 we expect 30% incidence. For patients in families with a history there is a 50% lifetime risk vs. roughly 12% risk for those without a positive family history. There are two forms, wet and dry. Dry is slowly progressive with the hallmark drusen spots in the center of the macula (where all detail seeing is focused). Drusen are defects at the boundary of the retina and the underlying vascular area the choroid. Small drusen can be watched safely in the early stages without any intervention. They are visible as white specs when your doctor looks inside the eye. Confluent drusen signal a later stage of ARMD. A small percentage of the these dry ARMD patients will progress to a wet form when blood vessels grow through Bruch's membrane from the choroid into the retina causing edema and disruption of normal vision. What causes this to happen? There are risk factors: high cholesterol, heredity(complement factor H polymorphism), lifetime of exposure to UV radiation, blue eyes, cardiovascular risk factors, smoking, and dietary influences. Prevention should be uppermost in the minds of those with a family history of ARMD. The AREDS study demonstrated the value of antioxidant formulations and is widely available now. AREDS II will be a study that further explores the need for dietary supplementation. Increasingly it is becoming clear that DNA is not destiny...i.e. the new science of epigenetics is giving insight into how genes can be switched on and off and the role that our diet can play. The trigger to the neovascularization that occurs is first the disruption of Bruch's membrane and the influence of VEGF or vascular endothelial growth factor. This growth factor is also responsible for vessel growth in tumors. Avastin is a drug that has been used and approved for colon cancer patients. It is now beginning to be used for wet macular degeneration. There are several other VEGF blocking drugs that are under investigation and there are other approaches such as VEGF trap and interfering RNA to either compete with VEGF function or to block it from being genetically expressed in the eye. PDT or photodynamic therapy has been used for some time now, but has not proved to be a magic bullet. A photoactive dye in combination with an exciting laser causes the death of ingrowing vessels. The treatment has to be repeated however. Combination treatments of PDT and Avastin plus intravitreal anti-inflammatories (Retaane or triamcinolone) should prove to be more effective than any one treatment alone. These studies are now ongoing. http://www.medpagetoday.com/Ophthalmology/GeneralOphthalmology/tb/4239 On the diagnostic side, optical coherence tomography has made evaluation of macular problems much quicker and easier on the patient. Newer versions of the OCT (spectral OCT recently FDA approved) will lessen the need for invasive studies such as flourescein angiography (the dye in the arm test). http://en.wikipedia.org/wiki/Optical_coherence_tomography New techniques and new drug use may in fact lessen the need for many of the surgeries done today. There is much more to be done, but there is real optimism in the the retina field today.

Doctor My Eyes Have Spots

It is not uncommon to see eyes with iris freckles like this. They can be normal variants or they can be a part of a syndrome called Iris Nevus-Cogan Reese Syndrome. Iris nevi usually do not grow but these patients can be at risk for corneal thickening, iris degeneration and possible glaucoma. Iris Nevus Syndrome is a subset of what is known as ICE or iridocorneal endothelial syndromes (Chandler's Syndrome and essential iris atrophy) that give rise to a spectrum of anterior segment changes. More serious causes of melanotic change in the iris would be melanoma which can be diffuse or localized. Melanomas are usually unilateral, usually elevated and may have feeder vessels or show other distortion of iris structure. Inflammatory granulomas may also appear on the iris surface and can be caused by Sarcoid or Tuberculosis. In addition syphilis, mongolism and neurofibromatosis patients can show iris changes. Chances are the eye in this picture is perfectly normal. Pigment is just out of place. If you have a friend or relative with similar eye changes it would be good advice to have a doc take a close look to verify that all is well. Close observation is usually all that is needed. Normal pigment can also be out of place on the whites of the eyes or sclera. Close inspection with a slit lamp biomicroscope is the only way to inspect these changes. There are certain fringe alternative "medicine" people who claim to be able to diagnose all manner of illnesses from the morphology of the iris. Iridology has no sound basis in or place in modern medicine.

Doctor I Have Pain in My Eyes

Your complaint will have to be carefully investigated. Before you go in for your visit try to think about the onset of symptoms, the location, the severity. Is the pain episodic or steady. On a scale of 1 to 10 how would you rate the severity? Is it surface pain like a foreign body or is is deep inside the eye? Also think about what makes the pain worse or better. Is it only when you read? Is it worse in the morning or afternoon? Have you had a significant sinus, ear or dental problem lately? Have you had an upper respiratory problem in the last week? Have you had any cold sores or herpetic mouth ulcers lately? Do you have vascular or migraine headaches? Is your vision affected before, during or after the pain? Is the globe itself tender? Are you photophobic? Are you a contact lens wearer who overwears lenses? These are a few of the points that you should be able to discuss with your doctor. Doctors often consider themselves lucky if they can elicit a good detailed history...but it is really essential to good care. Your symptoms must be evaluated in a context which gives further clues.

Disclaimer

It is hoped that the materials presented here are educational in nature. These articles do not in any way constitute specific medical advice concerning an ongoing pathology or illness. To get diagnostic and treatment advice you must visit your doctor. The internet is not the place to get specific medical help. It can function to give background and educate and I think this is a valuable tool for us all. I do not have editorial control over the websites that are linked to but seek to share the information contained there. I disclaim any liability for injury or damages resulting from review of this blog or the web pages linked to. It is my hope that you will be more informed and able to make decisions concerning your healthcare. The internet has many websites with questionable information. Notably the Bates method keeps cropping up. The Irlen" scotopic sensitivity syndrome" people....the pinhole glasses for everyone people etc. etc. The American Optometric Assoc and the American Academy of Ophthalmology issue position papers on certain subjects that are valuable in steering patients to more acceptable paths. www.quackwatch.com is also somewhat helpful, but a little severe in some pronouncements. One day I heard a commercial on tv that touted pinhole glasses to older drivers having difficulty with vision. I called the station manager and asked him what his liability was if an elder citizen donned pinhole glasses and then had a motor vehicle accident. His answer was that "If you have enough money you can advertise anything you want. We have no liability" . Prior to this I had seen a 79 year old man who had been sentenced to 15 years in the state penitentiary for running over 4 children at a bus stop and killing them....and driving away. He thought he had "hit some garbage cans or something". His remark to me was that he hoped I could give him stronger glasses. It was obvious that he had been blind for some time and that a state required exam should have kept him off the street. He was renewing by mail to another state up north. Do I think that he would have tried pinhole glasses for driving? ...unfortunately, yes. Losing one's privilege to drive is a life altering thing and the temptation is for some elder drivers to continue longer than they should. Florida's new elder driver rule let's us prove our visual competence every year after the age of 80. I personally think it should start at 75.

Healthcare Reform

In 1950 the country spent less than 100 dollars per year on each citizen for healthcare. That would be $500 in todays dollars. Eye exams ranged up to $18 on the high end. The current rate of spending for healthcare is $6000 per patient. If eye exams kept pace, that would be over $1000 for an eye exam...without glasses or contacts. Vision is a small part of the healthcare puzzle. The biggest social debate of the decade continues. Why have we stalled at this point? Political cowardice...apathetic voters....lack of news coverage...no view of how this affects ME? These web sites give a small taste of the viewpoints you will encounter. The twin plagues of HIV and Alzheimers continue to sap resources from an already overtaxed system. The worldwide HIV picture can be seen at this website http://www.who.int/hiv/countries/en/ There seems to be no end in sight. Short sighted politicians have hampered stem cell research and seem to suffer no consequences at the ballot box. An uninformed polity allows these missteps to happen. If there were real political pressure I think we might choose a wiser course. The following web sites are a little taste of what the opinion makers are pushing.

Alliance for Health Reform - Balanced information about the uninsured,
health care coverage and many other health policy issues.
and http://americanhealthcarereform.org/
and then follow this link to an excellent healthcare blog.
http://www.thehealthcareblog.com/the_health_care_blog/
the_industry/index.html

These web sites should give you insight into the vast and difficult task that reforming healthcare will be. We must begin somewhere. Our industries are crippled competitively for several reasons not the least of which is healthcare costs for their employees.
Forty six million without health care coverage in the USA. This is an astounding statistic. We all wonder why it takes all night to get seen by the emergency room staff but the uninsured and underinsured are clogging up the nation's emergency departments with situations and conditions that could be handled elsewhere if only they had adequate coverage. The self employed or the small businessman can barely afford to buy insurance for themselves much less employees. Where do we go from here folks? This system is badly broken. I am not sure that I agree with everything or even the majority of things on these websites, but we need to be talking about this and seriously moving toward some kind of consensus. The Clintons bit off more than they could chew but I respect them for trying. Fighting big medicine and big insurance and big pharmaceuticals all at once is tough unless popular opinion is solidly behind you. I thought Dr. Frist lost all credibility when he voiced an opinion on Terry Schiavo, a patient he had only seen a tape of. This was justified in his political thinking at the time I guess. Since his brother is a hospital executive with a national chain of hospitals I tend to look closely at any pronouncements he makes. He seems to me to be playing politics with the nation' s health. Pharmacy benefits managers and risk managers seem to be exerting undue influence on medical decisions as well. The book Enemies Of Patients by Ruth Macklin is an excellent analysis of some of the ethical problems involved in today's critical care. In closing, we spend 1.69 billion per year just to regulate healthcare! See this website for some proposed legislation: http://www.heritage.org/Research/HealthCare/wm803.cfm
If you add the amount we spend on healthcare worldwide and compare it to the amount spent on illegal drugs, alcohol and cigarrettes what do you get? The impression that we really don't take our own heath seriously. Check the stats http://www.worldometers.info/

Eyes and Aviation

There was a famous airliner incident in 1987 where a pilot wearing contacts belly flopped a 747 on landing because he had impaired depth perception. The investigation found that he was wearing contacts fit for one focal distance per eye i.e. mono-fit contacts. He saw distance with one eye and near with the other, but couldn't use the eyes together to achieve good depth perception. This was frequently done in the civilian population due to our lack of good bifocal contact lenses. All pilots should know that this type of fitting is not advised for flying. In general, today we have better options and several bifocal designs to choose from. Older pilots all have to contend with the bifocal problem eventually. For civilian aviation we can generally find a workable option that won't impair the visual judgements necessary to be safe. Anti reflective coatings for night flying are an advantage to eyeglass wearers since they get more light transmission through the lenses. UV blocking should be standard for anyone in the cockpit since exposure is greater at altitude. This is often a property of the lens material or can be added to traditional lens materials. This link is to a paper on glare and aviation accidents. http://www.hf.faa.gov/docs/508/docs/cami/0306.pdf
The DOT/FAA do not advise the use of polarized lenses.

Refractive Surgery Gets Better

One complication that all lasik docs dread is flap problems either from malpositioning and slippage or inflammation under the flap. This has been such an issue that some have gone back to prk instead of lasik claiming better results (no flap involved).
Some studies have indicated that prk can give better vision than lasik. Military pilots are usually limited to PRK for this reason and concern over flap stability. The healing and pain issues with prk are controlled much better with newer medications. One of the latest lasik advances, Intralase, makes a cleaner flap interface without using a blade and probably removes less or the same amount of tissue as compared to conventional lasik. The ability of the older keratome blade to slice a flap of consistant thickness was always suspect. If your corneas are thick this may not be a problem in terms of your proposed correction. Intralase makes progress in lasik accuracy and safety due to better control of the flap making procedure. A very fast femtosecond laser makes the flap cut with no blade involvement. The laser cycles and fires in an extremely fast manner measured in femtoseconds. A femtosecond is a billionth of a millionth of a second. Wavefront analysis or aberrometry is also guiding lasik into an era of more predictable results. The ability to treat higher prescriptions is also making strides. The Star S4 in now able to treat from -14 myopia to +5 hyperopia and 5 diopters of astigmatism. This may vary with the proposed procedure i.e. lasik vs prk. The incidence of post lasik farsightedness in nearsighted corrections has been reduced due to better algorithms and better understanding of the cornea. Results with hyperopic patients tend to be a little less stable than myopic corrections. Your doctor will go over the risks and discuss any concerns you may have. Your cornea will be mapped and the thickness checked. Pupil size is also a concern with larger pupils more at risk for glare and halos. Old records should be reviewed to see if you have stable corneas and stable refraction. If you have developed several diopters of astigmatism over the last several years this may be enough change to be a contraindication to surgery. Until a records review is done it is premature to proceed with surgery. The FDA has as website that is very helpful in giving an overview of the technology and concerns that need to be addressed when making the decision to pursue refractive surgery. http://www.fda.gov/cdrh/lasik/
Perhaps the best website available for this purpose is http://www.refractivesource.com

GLOBAL WARMING

Wired 14.12: START Even if you don't believe in global warming as a manmade phenomenon, do you want to take the chance that you are wrong ? It seems there is a burden of proof both ways...proove it's real or prove it's wrong. The stakes are very high.
So what can we do about global warming? Is this like stopping plate tectonics? I hope not for the sake of future generations. See this link for some exciting research http://en.wikipedia.org/wiki/Iron_fertilization#Carbon_sequestration From a healthcare perspective, warming could serve to spread diseases (lyme, malaria, dengue etc.) to more temperate locales. In 1878 yellow fever wiped out Memphis and several other cities along the Mississippi. This is a real threat. I am not at all sure that our preventive health services and health departments are up to the challenge. So it is not just the plant life that would suffer in a warming scenario. The 30,000 remaining wild tigers in the world would see their habitat shrink more and more rapidly while poor farmers continue to exploit them and their land. This link details the sinking of some islands in India that are crucial tiger habitat: http://www.breitbart.com/news/na/061221021851.h3kfaxex.html Did the Easter Island natives die off because they exhausted their resources? Probably. Could this happen to us? It seems a no brainer to say that fossil fuels must be replaced with new technology. Fuel cells, hydrogen and electric power may all have a part to play. Recent advances in nanotechnology will make advances accelerate. Photovoltaics and superconductivity are also going to play a role in the near future. If fusion could be reliably harnessed it may provide clean power. Recently a high school student cobbled together a working fusion device in his garage. http://www.freep.com/apps/pbcs.dll/article?
AID=/20061119/NEWS03/611190639
/NEWS03/611190639
What it will take is politicians with the guts and vision to take us to a new non-polluting sustainable energy future. Oil companies predict that all the cheap oil is dwindling and seek to find new oil fields in 7,000 feet of water beneath 4 miles of rock. The Jack2 reservoir off Louisiana could supply oil, but at 3-4 times the cost of a land well. Tax credits and incentives from the feds will expire in 2007. Let's hope the direction taken will be towards increasing these incentives. Ultra-capacitors will replace batteries in electric cars and fuel cell systems will also be available for home or auto use. This seems to me to be more of a long term solution than just diluting our gas with ethanol. Forty eight ethanol plants are currently under construction in the U.S. however, with big oil hoping that a diluted dependence is better than losing out to hydrogen. Have you heard about the Tesla electric from silicon valley? 0 to 60 in 4 seconds! In addition to politicians, it will also take scientists that are not shackled by the conventions of peer review...those bold enough to swim against the tide of conventional wisdom. Think Tesla, think Filo T Farnesworth. http://http//www.farnovision.com/chronicles/fusion/vassilatos.html
and http://www.everything2.com/index.pl?node_id=1682107&lastnode_id=0
and http://farnovision.com/chronicles/fusion/
Lawrence Livermore labs has this to say about Global Warming http://www.llnl.gov/pao/news/news_releases/2006/NR-06-09-02p.html
African freshwater lakes are drying up quickly and there is the possibility that the Nile may be drastically affected. http://apnews.myway.com/article/20061210/D8LTL4K01.html
I think Al Gore was right to worry about theses things even though he was ridiculed in the press by those with less of a scientific background than he himself had. It would seem that his study of the situation has rightly pointed out a 21st century quandary: how do we mitigate our ecological footprints so that we don't trash the planet? A very real possibility is the re-discovery of HHO and the retrofit of existing autos to run on a mixture of gas and HHO... and then down the road to run on just HHO. Or is this just snake oil in another bottle? I think we should take it seriously don't you? A Google search on this will turn up many sources and even videos of exciting new possibilities. We may be able to run cars on a fuel with more energy than gasoline and the stability of water. There is a list of proposed actions to be considered by the next congress at this link: http://www.pewclimate.org/what_s_being_done/in_the_congress/109th.cfm
http://www.physorg.com/news85938220.html

'Termite guts can save the planet', says Nobel laureate from PhysOrg.com

The way termite guts process food could teach scientists how to produce pollution-free energy and help solve the world's imminent energy crisis. Speaking at the Institute of Physics conference Physics 2005 in Warwick today, Nobel laureate Steven Chu urged scientists to turn their attention to finding an environmentally friendly form of fuel. In an impassioned plea to some of the world's brightest minds, he explained how he's leading by example, and encouraged others to join the effort which "may already be too late."

[...]

British meteorologists have predicted 2007 to be possibly the warmest year in recorded history. I currently live about 1000 yards from the Gulf of Mexico, but at the end of the summer I could be a little closer to having beachfront property as the water levels will surely rise. The Kyoto Protocol would have seemed to be a reasonable first step in global cooperation...reasonable to everyone except the Bush administration. I think we will get the opportunity to revisit this decision as it becomes more and more apparent that we should at least try to change the direction of or the magnitude of the climate changes.

I Have Eyes for You

The Anableps fish has eyes that allow him to see above and below the waterline...simultaneously. His eyes have 2 foveal areas that allow clear focusing when he cruises with the waterline splitting the pupil. This allows him to have both worlds in focus at the same time. Here he is in shallow water and intent on an above water target. There are several species of these fish. Archer fish are a common aquarium pet and also have the ability to see and hunt in water and in air. Their ability to spit water at a target to bring it down into the water gives them their name. A recently discovered fact is that sea urchins have photo sensing capability in their feet. As their genome has been unraveled it is clear that this rudimentary "vision" exists. Previously no one had suspected that urchins could really sense anything close to vision. Raptors, birds of prey, have also evolved a second fovea and have stereo vision or depth perception for rapid localization as they dive at tremendous speed. The Limulus polyphemus or horseshoe crab is also notable for the size of its optic nerves. These are used in research simply because the size makes it easier to work with. Research may one day allow us to regenerate optic nerve tissue and restore human vision to those who have had damage. As our population ages there are more and more of us that will one day benefit from knowledge gained by studying the comparative biology of vision and eyes. There is a recently discovered oddity in Madagascar...a moth that feeds of the tears of sleeping birds. There are plenty of insects that attack eyes but this one has a forked and barbed proboscis that helps penetrate the birds closed eyelid to gain access to fluid.http://www.newscientist.com/article.ns?id=dn10826
Obviously there are many wonderful and sometimes terrifying adaptations and designs that mother nature has in store.

OSHA, safety glasses and you

Probably an unpopular topic but a very very important one: safety glasses and why they are necessary. Today I saw a young man for the second time this month with a nail gun injury to his eyes. He was lucky last time and only had an embedded piece of metal which was extracted with some difficulty. It did leave a scar but luckily it was not in the pupillary area. If it had been, he would have lost at least 2 or 3 lines of acuity i.e. from 20/20 to 20/40. Today he was not lucky and came in with an injury to the other eye. He had been wearing some cheap sunglasses which were shattered. It is hard to say that OSHA approved lenses would have helped him avoid any injury, but chances are good that it would have mitigated the trauma to his eye. As it is, he was 20/200 and in great pain. There was bleeding in the eye and a probable retinal detachment. He was turned away at 4 o'clock by one of the local hospitials but they said that he needed to be seen" right away by an eyedoc". Maybe they dropped the ball here, but after a visit to my office and a long talk about safety,the retinal specialist saw him right away. It will be several weeks before we know how this turns out. The optic nerve could also be damaged. I am sure that this young man now understands the necessity of good quality safety eyewear. Typically safety glasses are made of polycarbonate or perhaps newer more impact resistant plastics. If your safety officer at work can't help you with a safety eyewear program please contact your doctor's office for advice. You can't always count on being lucky with these injuries. To be compliant with OSHA the frame and the lenses must be of approved type and should not be reglazed with replacement lenses. Your eyewear professionals know the rules. Please take advantage of their knowledge. This website has the lowdown on all ANSI standards. Z87.3 is the safety eyewear standard. There are other standards for sports goggles and face shields etc. http://webstore.ansi.org/ansidocstore/default.asp?source
=google&adgroup=ANSI&keyword=
ansi&gclid=CIaujc7I2ogCFSAnSgode0pNtw

Concerning the eye accident mentioned above: initial evaluation by retinologist said he was ok but he subsequently detached 2 days later. This was repaired and vision should be relatively good because of quick response to the problem. This illustrates the problem of delayed detachment. Sometimes retinas can detach months after an injury that was initially thought to be minor. Any sudden onset or change in floaters or flashes of light or "smoke" or "water running in the eye"...should be addressed quickly. Remember small areas of damage can evolve over time to become sight threatening tears, rips, detachments, etc.

Twenty First Century Eyecare

Post cataract implants that actually focus like your original lens, oxygen permeable contacts, contacts that release medication into the tear film, contacts that can sense blood sugar level, the ability to switch on or off some genes that may affect vision, new antibiotics to treat infections, new rehabilitative approaches to dyslexia, low vision and of course new surgical approaches to the remediation of dysfunctional and diseased eyes...these medical advances are all close to being realized. ReZoom and Restore intraocular lenses are now being implanted and I am sure there will be better designs to come. They cost a little more than what Medicare or most insurances will allow, but promise better function. Newer approaches to refractive surgery may finally take some of the risk out of the procedures. The new genetic understanding realized by the genome project has already shown us the way to new targets for medical therapies. We are now able to test glaucoma family members to see if they are genetically predisposed to developing the condition. These tests will be refined in the next decades to give us earlier warning. The ability to switch a gene on or off will be a very powerful tool for all of medicine. The field of muscular dystrophy is benefiting from recent discoveries of proteins that encourage muscle growth. The biggest problem we will have is to find a way to pay for the newer technologies. There is something wrong with the governmental- medical interface. It is sad when our citizens have to resort to internet drug sales or crossing the border to get affordable medicines. Politicians simply don't have the guts to fix this problem. The Medicare donut hole and Medicare D in general is a flawed program. The drug companies must be brought to the bargaining table if this is to be fixed. As much as organized medicine dislikes it, we may have to go to a single payer system. Can you hear the insurance companies protesting? Accountability will have to be brought to the whole field. HMO's are notorious for rationing health care largely by patient confusion. Canada may not have a great system , but at least they don't spend 25 cents of every health care dollar on paperwork like we did in the last decade. I recently moved my office from one end of Palafox St to the other end....63 days later, I still don't have the government/FCSO/PGBA required paperwork straightened out so that I can see Medicare and Medicaid patients and bill for their visits. Paperwork just adds inertia to the whole system and creates paper- shuffling jobs that up your health care costs. This is where political pressure must be placed. And as a doctor, I don't care if I ever see another drug detail person or sales rep. It's just another trapping of a system gone overboard and allowed to run rampant by drug company patronage to regulators and officials at all levels and political lack of will to fix the problems. The FDA's performance over the last decade is a case in point. It will take real leadership to even begin the process of reform, but it must be done. George Bernard Shaw acerbicly observed that "the professions are a conspiracy against the laity". It seems to me that the beaurocrats and paper pushers conspire against both the professions and the laity and allowing the current state of affairs to continue is a travesty.

Whoo does your eyes?

In the animal kingdom eyes take many shapes and sizes. The largest known eyes are the eyes of architoothus the giant squid or his realative the colossal squid. These eyes may approach the size of a dinner plate. This size is necessary to allow gathering of all available light in the deep undersea environment. Weird compound eyes of the insect kingdom or perhaps the blue eye spots of the scallop seem very curious to us, but when the environment they live in is considered it makes more sense. Take your average housecat on the prowl for whatever it can pounce on or play with. Under her retina is a layer called a tapetum which gives a double bounce effect to the light rays entering the eye. It effectively helps in the motion sensing function for this efficient predator. Humans don't have this layer but we do have a subset of retinal ganglion cells (magnocellular cells) that are used in the location and motion sensing system. This function was evidently very important for both prey and predator. A very interesting web site for further information is http://ebiomedia.com/gall/eyes/eye1.html
Another fascinating site gives an overview of primitive compound eyes in trilobites.www.trilobites.info/eyes.html and another paleobiology site: http://www.lifethroughtime.com/

Psssst!

Psst! Over here! If you are a senior or have medicare aged parents or family members you need to be aware of the website that helps seniors with choosing a Medicare plan D provider for drugs. This is way overcomplicated don't you think? Anyway try this website and then vote out everyone that signed on to this plan. How much simpler to just negotiate better pricing from the drug manufacturers....it boggles the mind how many ways we can mess up medicare. All providers listed are approved by Medicare, but some may not be in your area. This tool allows you to check it out. Good luck! http://www.medicare.gov/MPDPF/Public/Include/DataSection/Questions/SearchOptions.asp

What is wrong with this picture?

What's wrong with this? They were cheap and I see fine. Well, let's start with the size. They seem a little big and may in fact rest on your cheeks a bit. So you can expect the metal to corrode inferiorly and on the temples...depending on how cheap they were. If you have had problems with corrosion in the past, I would advise a titanium frame. If you are allergic to metals I would advise titanium also. They will be more expensive but they will last twice or three times as long as your typical cheap frame.
And what about those reflections? You lose about 4% of the light coming to you at each surface...so about 8% is lost here. If you already have night vision problems , 8% is too much to sacrifice. This one option does make glasses significantly more expensive, but gives better vision under difficult driving conditions. If you have a large prescription, then the shape is alright, but the size is definitely on the large side and will cause the edges to be thicker than in a small frame. Aspheric and atoric lenses are now on the market and will mask the thick edges that are a giveaway that you have a large refractive error. The average price of a pair of glasses sold in the US ranged up to $175 in the late 90's. Now it is more, but people are much more satified with their correction and I believe they see better as well. Granny's glasses with the lines are not an inevitable end point for the 40 and above crowd. If you tried progressives in the past and were not successful, take heart...the new progressives are much better. We still have some adaptation problems but they are usually with more complicated prescriptions. Be sure to ask what the performance warranty is on the lenses you buy. If you have a simple light prescription you may be successful in ordering glasses on the internet, but sooner or later as your prescription gets more complicated, you will have to come up to quality. There is no way to do today's precision eyewear at bargain basement prices and supply quality goods and warranties. Make no mistake, there is a degree of precision needed to do your eyes justice.

Refractive Surgery Caveats

Lasik effects on glaucoma testing can be unpredictable. I am aware of several patients in my area that had undiagnosed glaucoma due to the masking effects of a thinner cornea. Now that we know how to compensate readings, there is much less of a risk. Be aware that not all offices will have the correct equipment (a pachymeter) to help gauge pressure effects. New tonometers that are independent of thickness are becoming the standard of care. Make sure that when you have followup on your laser procedure that the pressure is being correctly measured. here are some references on the subject:

Munger R, Hodge WG, Mintsioulis G, et al. Correction of intraocular pressure for changes in central corneal thickness following photorefractive keratectomy. Can J Ophthalmol 1998 Apr;33(3):159-65.

Chatterjee A, Shah S, Bessant DA, et al. Reduction in intraocular pressure after excimer laser photorefractive keratectomy. Correlation with pretreatment myopia. Ophthalmology 1997 Mar;104(3):355-9.

Kaufmann C, Bachmann LM, Thiel MA. Intraocular pressure measurements using dynamic contour tonometry after laser in situ keratomileusis. Invest Ophthalmol Vis Sci 2003 Sep;44(9):3790-4.

Siganos DS, Papastergiou GI, Moedas C. Assessment of the Pascal dynamic contour tonometer in monitoring intraocular pressure in unoperated eyes and eyes after LASIK. J Cataract Refract Surg 2004 Apr;30(4):746-51.

Complication rates and the handling of suboptimal results depend on the definition of success. There will be noone who can guarantee you a certain endpoint (20/20, 20/25/, 20/"happy"). Wavefront seems to help avoid some of the postop surprises that used to occur and statistically the results are better than those of 5 years ago. Some surgeons who use both wavefront and standard laser treatments will tell you that patients don't always require the wavefront guided treatment. Wavefront will cost slightly more. Always understand the doctor's policy on second surgeries...or refinements. Have them demonstrate what 20/40 looks like since this seems to be the level at which some clinics deem you eligible for a redo. If everyone had a clear understanding of the disclosures before surgery it would be much better for patient and doctor. In the early days of lasik, people used to go to Canada and Mexico and even Columbia for the latest laser treatments. Our FDA approval process made us lag a bit behind the Europeans as well. Currently I can think of no reason to leave the country to get lasik. Unfortunately, I saw a patient who had gone to Canada for a cheapo laser treatment and had terrible results. It was because she had a corneal condition that should have ruled out laser treatment. She had a very good legal case, but the cheapo place had gone out of business and she would have had to pay lawyers on both sides of the border. She got a cheap price for the procedure without any provision for followup. Be sure you know what provisions are made for follow-up and any complications. This is surgery and there can be unforeseen outcomes. Thankfully, they are fewer and fewer as the technology matures. Aberrometry may move from Zernike polynomial analysis to Fourier analysis in the future. Clinically it may not matter that Fourier is more detailed, but the mathematical treatment of aberrations may change. Astronomers have been using this type of analysis of optics for quite some time now. This site is for the mathematicians among us. http://www.iovs.org/cgi/content/full/46/6/1915
Many "complications" can be avoided if the patient is well informed before the procedure and understands the healing process. Knowing what to expect is crucial to your final satisfaction with the procedure. This is an FDA site that helps in decision making: http://www.fda.gov/cdrh/LASIK/reduce.htm

Twenty First Century Eyecare

Eyecare Progress

In the 25 years since I graduated from optometry college, eyecare has made great strides in providing better quality goods and services. Computerization has largely made our accuracy better and our ability to work efficiently has been enhanced greatly. Old turf wars flare up sometimes when the three O's can't seem to agree (opticians, optometrists, ophthalmologists). Just to put an old feud to rest, the latest research by OD's and ophthalmologists indicates that judicious use of bifocals may slow myopia progression. This has been a bone of contention between OD's and MD's for many years now. Early optometric practices in this regard now seem justified. On other fronts federal laws now mandate prescription release for both professions and better cooperation can be seen in many areas. Lasik is one area where comanagement does seem to work. I would encourage all who contemplate lasik, lasek, prk, refractive implants and corneal moulding or the new orthokeratology to do a lot of homework and surf the web for all sides to a complex decision. Understand that glasses may continue to be a part of your visual correction even after the proposed treatments. Word of mouth is perhaps a good metric. You will see many many ads with docs all claiming to be the best, most experienced and best equipped. It is hard for the patient to filter out the puffery. There have been some missteps along the way and you will see these chronicled on the web. Some laser "chains" have been fined large amounts for their handling of disclosures and pre-op fees. As with any surgery, there can be mishaps and or a mismatch between expectation and final results. So, start with an eye exam to judge your suitability and motivation to proceed. If you have a good rapport with your current doctor then start there. A good website : refractivesource.com

Doctor My Eyes Need Treatment But I Can't Afford It

I know several eyedocs that have made it a point to join in efforts to supply much needed eyecare to developing (or not developing) nations in the third world. Their efforts are largely self funded. Students organizations at schools of optometry known as SVOSH are involved in programs such as this. If you get the opportunity please support these efforts by donating old glasses to them for redistribution to very needy folks who don't have many options. Of course the local Lions Club in your area does the same thing here in the US. If you know of people who fall through the cracks and don't have the resources, then vocational rehab organizations may be of help. Prevent Blindness also does charitable work. Many drug companies now have programs for indigent patients needing medications. It is always sad to see a patient who couldn't afford glaucoma medication who then subsequently goes blind needlessly. Your local eyedoc should have the ability to point these people in the right direction. This link is to a view of world poverty that makes many valid points. I would add that the US is not immune from this same analysis and that global politics has a great part to play. http://www.reason.com/news/show/33258.html?id=05dr3

Doctor My Kid's Eyes Are Bad

Doctor My Childrens Eyes
I would like to direct you to the Vision Council of America's web sites....www.visionsite.org and www.checkyearly.com/ In vision care as in other walks of life there are controversies and strong opinions...some based in science and some based in prejudice rooted in economic interest. I am reminded that the organized religion that persecuted Galileo took 319 years to admit that they were wrong and had reconsidered the evidence. Turf wars abound in visual subject areas. For example, take dyslexia. Psychologists, educators, ophthalmologists, optometrists, and orthoptists have all written profoundly on the subject. They frequently pontificate that their answer is the only way. Reading problems do not have a monolithic cause and have a mixture of aetiologies. Certainly if a vision problem overlaps a processing problem, then it may impede any progress in remediation. After 100 years we are still only beginning to unravel some of the causes. I would basically disregard most if not all of the old literature on the subject and concentrate on research within the last 10 years. I can recommend a book by Sally Shaywitz MD called Overcoming Dyslexia. Future reasearch will uncover many other avenues to pursue.
Juha Kere and her colleagues at University of Helsinki in Finland and the Karolinska Institute in Sweden have discovered that a flaw in a gene called DYXC1 may cause dyslexia.

They suggested [DYXC1] may be involved in helping cells cope with stress but they acknowledged that much more study is needed. They added that faults in other genes may also cause dyslexia.
But writing in the PNAS, they said: "We conclude that DYXC1 should be regarded as a candidate gene for developmental dyslexia."
They added: "There is overwhelming evidence that dyslexia is a genetically complex condition."

What is our responsibility to the kids? Do screenings at school do a good enough job? The answer is that there is no substitue for a good eye exam done in the doctor's office. There are simply too many distractions at school and not enough manpower. The pediatric doc is probably not well enough equipped to detect things such as latent hyperopia or small angle squints that can affect reading performance. And folks , most of the time they will not grow out of it! A recent study found severe shortcomings in school screenings as currently done. Paradoxically, some powerful ophthalmologists are on record as opposing mandatory school screenings...whose side are they on anyway? They are certainly not serving as advocates for the kids in my view. The Vision Council of America has more data on the state by state efforts to pass laws that help us discover visual problems before they become more severe perhaps lifelong problems. Here the turf wars become very intense and hotly contested. My advice: if your kid has reading problems, start with a vision exam. Psychologists are fond of saying that reading problems (the monolithic dyslexia) are not caused by eye related difficulty. My response is that while there are pure processing problems there are a subset that may have visual factors of poor reading efficiency. I guess you could say that if you really believe that eyes don't impact reading, close both eyes and read the rest of this blog. ;-)

Doctor My Eyes

Doctor My Aging Eyes
An all to common form of retinal degeneration centered in the macula has been found to be linked to genetic variants (polymorphisms) that can explain a large number of cases of age related macular degeneration. This is just one of the newly discovered polymorphisms that can contribute to risk of blindness.

Originally published in Science Express on 10 March 2005 Science 15 April 2005: Vol. 308. no. 5720, pp. 419 - 421 DOI: 10.1126/science.1110359 here is the abstract of this article:

Reports

Complement Factor H Variant Increases the Risk of Age-Related Macular Degeneration

Jonathan L. Haines,¹ Michael A. Hauser,² Silke Schmidt,² William K. Scott,² Lana M. Olson,¹ Paul Gallins,² Kylee L. Spencer,¹ Shu Ying Kwan,² Maher Noureddine,² John R. Gilbert,² Nathalie Schnetz-Boutaud,¹ Anita Agarwal,³ Eric A. Postel,⁴ Margaret A. Pericak-Vance^2*

Age-related macular degeneration (AMD) is a leading cause of visual impairment and blindness in the elderly whose etiology remains largely unknown. Previous studies identified chromosome 1q32 as harboring a susceptibility locus for AMD. We used single-nucleotide polymorphisms to interrogate this region and identified a strongly associated haplotype in two independent data sets. DNA resequencing of the complement factor H gene within this haplotype revealed a common coding variant, Y402H, that significantly increases the risk for AMD with odds ratios between 2.45 and 5.57. This common variant likely explains 43% of AMD in older adults.

¹ Center for Human Genetics Research, Vanderbilt University Medical Center, Nashville, TN 37232, USA.
² Center for Human Genetics and Department of Medicine, Duke University Medical Center, DUMC Box 3445, 595 LaSalle Street, Durham, NC 27710, USA.
³ Vanderbilt Eye Institute, Vanderbilt University Medical Center, Nashville, TN 37232, USA.
⁴ Duke University Eye Center and Department of Ophthalmology, Duke University Medical Center, Durham, NC 27710, USA.

In more detail the combination of genetic markers may predict 74% of ARMD ! click this link:

http://www.rxpgnews.com/research/ophthalmology/retina/ARMD/article_3599.shtml

Prevention may be our best approach to this condition regardless of the genetics:

Antioxidants reduce risk of age-related macular degeneration Dec 28, 2005, 18:23, Reviewed by: Dr. Priya Saxena

"This study suggests that the risk of AMD can be modified by diet; in particular, by dietary vitamin E and zinc. A higher intake of vitamin E can be achieved by consumption of whole grains, vegetable oil, eggs, and nuts. High concentrations of zinc can be found in meat, poultry, fish, whole grains, and dairy products. Carrots, kale, and spinach are the main suppliers of beta carotene, while vitamin C is found in citrus fruits and juices, green peppers, broccoli, and potatoes. Based on this study, foods high in these nutrients appear to be more important than nutritional supplements. Until more definitive data are available, this information may be useful to persons with signs of early AMD or to those with a strong family history of AMD. Although in need of confirmation, our observational data suggest that a high intake of specific antioxidants from a regular diet may delay the development of AMD"

By JAMA, A diet with a high intake of beta carotene, vitamins C and E, and zinc is associated with a substantially reduced risk of age-related macular degeneration in elderly persons, according to a study in the December 28 issue of JAMA.

Age-related macular degeneration (AMD) is a degenerative disorder of the macula, the central part of the retina, and is the most common cause of irreversible blindness in developed countries, according to background information in the article. Late-stage AMD results in an inability to read, recognize faces, drive, or move freely. The prevalence of late AMD steeply increases with age, affecting 11.5 percent of white persons older than 80 years. In the absence of effective treatment for AMD, the number of patients severely disabled by late-stage AMD is expected to increase in the next 20 years by more than 50 percent to 3 million in the United States alone. Epidemiological studies evaluating both dietary intake and serum levels of antioxidant vitamins and AMD have provided conflicting results. One study (called AREDS) showed that supplements containing 5 to 13 times the recommended daily allowance of beta carotene, vitamins C and E, and zinc given to participants with early or single eye late AMD resulted in a 25 percent reduction in the 5-year progression to late AMD.

Redmer van Leeuwen, M.D., Ph.D., of Erasmus Medical Centre, Rotterdam, the Netherlands, and colleagues investigated whether antioxidants, as present in normal daily foods, play a role in the primary prevention of AMD. Dietary intake was assessed at baseline in the Rotterdam Study (1990-1993) using a semiquantitative food frequency questionnaire. Follow-up continued through 2004. The Rotterdam Study included inhabitants aged 55 years or older from a middle-class suburb of Rotterdam, the Netherlands. Of 5,836 persons at risk of AMD at baseline, 4,765 had reliable dietary data and 4,170 participated in the follow-up.

Average follow-up of participants was 8.0 years. During this period, 560 persons (13.4 percent) were diagnosed as having new AMD, the majority of whom had early-stage AMD. A significant inverse association was observed for intake of vitamin E, iron, and zinc. After adjustment, a 1-standard deviation increase in intake was associated with a reduced risk of AMD of 8 percent for vitamin E and 9 percent for zinc. An above-median (midpoint) intake of beta carotene, vitamins C and E, and zinc, compared with a below-median intake of at least 1 of these nutrients, was associated with a 35 percent reduced risk of AMD, adjusted for all potential confounders. In persons with a below-median intake of all 4 nutrients, the risk of AMD was increased by 20 percent. Adding nutritional supplement users to the highest quartile of dietary intake did not change the results.

"This study suggests that the risk of AMD can be modified by diet; in particular, by dietary vitamin E and zinc. A higher intake of vitamin E can be achieved by consumption of whole grains, vegetable oil, eggs, and nuts. High concentrations of zinc can be found in meat, poultry, fish, whole grains, and dairy products. Carrots, kale, and spinach are the main suppliers of beta carotene, while vitamin C is found in citrus fruits and juices, green peppers, broccoli, and potatoes. Based on this study, foods high in these nutrients appear to be more important than nutritional supplements. Until more definitive data are available, this information may be useful to persons with signs of early AMD or to those with a strong family history of AMD. Although in need of confirmation, our observational data suggest that a high intake of specific antioxidants from a regular diet may delay the development of AMD," the authors conclude.

- December 28 issue of JAMA

JAMA . 2005;294:3101-3107