Eye on New Vision Procedures

Last Editorial Review: 6/8/2005

WebMD Live Events Transcript

It's Healthy Vision Month. Would you like to see what's new in eye care? WebMD vision expert Bill Lloyd, MD, discussed the latest vision procedures on May 18, 2005.

The opinions expressed herein are the guests' alone and have not been reviewed by a WebMD physician. If you have questions about your health, you should consult your personal physician. This event is meant for informational purposes only.

Welcome to WebMD Live, Dr. Lloyd. Thank you for joining us today.

It's great to be here. Summer and springtime is a great time to celebrate our wonderful vision over the months ahead. We're going to be spending lots of time outdoors, lots of time with family, and lots of time engaged in fun activities. Hopefully, we will learn some important ways to preserve our precious vision during this exciting time of year. Who wants to be first?

So many wonderful things to see! But is it inevitable that as we age we are going to lose our visual acuity?

Vision changes throughout life. The vision you have at birth is very different than what you have at 35 and 65. Having said that, you should be able to see clearly throughout your life. Changes occur, just like life, but by taking good care of your health, you should be able to hold on to precious eyesight.

One way to ensure continued clear eyesight is to make sure you have a periodic eye examination. That way, early detection can prevent/treat the most common causes of vision loss in adults -- cataract, glaucoma, and macular degeneration.

How often should you get an eye exam?

For folks without active eye problems, every one to two years is acceptable. If you are at risk for eye diseases like glaucoma (perhaps because of your family history) you'll need more frequent exams -- at least once a year. Everyone is different, so your eye doctor will tailor an examination schedule that best meets your needs.

"I cannot encourage patients already diagnosed with clinical dry eyes to use contact lenses. It just doesn't make sense to put up with all that irritation."

I have inflammation of the blood vessels on the whites of my eyes. I wore contacts for only one-and-a-half years and everything was fine until I noticed some red veins. I took my contacts out and everything calmed down, but one or two remained. I didn't think anything of it. However after four months it got worse and the blood vessels are becoming more prominent. They always burn -- while in front of my CPU, watching TV -- anything. I have been diagnosed with dry eyes, but the drops don't do a thing. I am going to see an ocular surface specialist. Can my dry eyes stabilize?

Thank you for that very clear, yet complex, history.

Let's talk first about those pesky blood vessels. The truth is -- those tiny vessels have always been there! It's just that when the eye is irritated, these tiny vessels enlarge and become very visible. By alleviating the irritation, you can maintain a white and quiet appearance to your eyes.

Now, you've introduced some extra information. You mentioned your eye doctor's suspicion for dry eyes and you still wear contact lenses. It's a great idea to see an ophthalmologist specializing in ocular surface problems, because contact lenses compete with the eye for those moist tears. Contact lenses work because they utilize the tear film to help focus a clear image. However, the eyeball needs that same fluid for oxygen and nutrients. It's a tug of war! In folks with borderline dry eyes or full-fledged dry eyes, you could see how the surface of the eye can really suffer.

I cannot encourage patients already diagnosed with clinical dry eyes to use contact lenses. It just doesn't make sense to put up with all that irritation.

I have not worn my contact lens since I noticed the red veins. I took them out right away, but the blood vessels became more inflamed. Why did they become inflamed afterwards? Shouldn't it have calmed down?

The persistence of those blood vessels is a signal that the eyes continue to remain irritated. Perhaps it remains a dry eye issue or perhaps there are other factors contributing to this annoying situation. Your local eye expert is best qualified to evaluate your red eyes and offer prompt treatment. Good luck!

Another question about dry eyes: What do you think about nonpreserved methylprednisolone for the treatment of dry eyes? What's the idea behind this steroid drop? I've seen clinical pictures and I was amazed!

First let's talk about the phrase "preservative free." If you receive eye medications in a bottle with a cap, that means that product has an extended shelf life. The contents (eye drops) remain pure because of chemicals that were added to keep the solution sterile; these are preservatives. As helpful as preservatives are, over time the eye will develop sensitivity to them. That's one reason why patients often experience discomfort when using the same eye drops month after month after month.

I do not prescribe artificial tear supplements that contain preservatives. I recommend that dry eye patients utilize tear supplements that are preservative free. They are typically packaged in daily-use disposable vials. You use the vial all day long and toss it away at the end of the day. Never reuse one of these vials overnight since the preservative-free solution may become contaminated.

You also mentioned the role of topical steroid. We now know that many patients with dry eyes are experiencing an autoimmune problem. A person's inflammatory cells have decided to attack the tiny glands along the inner surface of the eyelid that produce the water component to our tears. Did you know that tears are made up of water, mucus, and a little bit of oil -- kind of a goofy Caesar salad dressing? For these patients it is reasonable to prescribe a mild anti-inflammatory eye drop to tackle the root cause of their dry eyes.

This strategy does not work for all dry eye patients, and any patient taking chronic steroid eyedrops needs continuous follow-up by an experienced physician. Follow-up is necessary because these patients are at risk for potential problems related to topical steroid use.

Another group of patients needs more powerful help for their dry eyes. These patients are often prescribed strong topical immunosuppressive eyedrops, like Cyclosporine.

Your local eye doctor should know which treatment will work best for your dry eyes. Thank you for your interesting question.

"Bottom line: patients should select surgeons they trust and not worry about the gadgets. Let the doctor worry about the gadgets, while keeping your best vision a priority."

I'm 56-year-old female and I wear glasses for my reading vision. Why does this change about every 18 months? Also, what's new for correcting vision at my age? My health is fairly good, although I have been treated for mild hypertension for many years.

You raise many important points. Let's take them in order.

The ability to see at "near" is called accommodation. Accommodation is a different focusing system than what we use to see at distance. As we get older, our ability to accommodate decreases steadily. We compensate well for this decrease until our 40th birthday or so (sometimes sooner, sometimes later). All of a sudden, people notice that they have to hold documents further away in order to see clearly. Soon, their arms are not long enough! Eye doctors can prescribe proper reading eyewear but the prescription will only be good for several years because the eyes' ability to accommodate continues to decline. That means individuals have to periodically update their reading correction. By age 65 or so, the gas tank is empty and patients receive the maximum allowable reading correction -- typically 2.50 diopters. After that, you rely on reading glasses all the time in order to accommodate.

In regards to vision correction in older age, you already know how precious your eyesight is. Having good vision is vital to having a satisfying life. We know this as a fact. Patients who lose eyesight often become depressed and lose interest in other life activities. No one is exempt from having regular eye exams. Most of the causes for lost vision (regardless of age) are easy to diagnose and very treatable. Yes, there are exceptions, but let your eye doctor make that discovery.

Have they perfected laser surgery for
farsightedness (reading)? What are your recommendations?

The short answer is yes, there are refractive surgery solutions for patients who are farsighted -- we call these patients hyperopes. Hyperopes are just the opposite of nearsighted myopes, because uncorrected hyperopes focus their visual image behind the retina. Hyperopia is corrected with plus power lenses (+2.50) to shift that image forward back onto the retina. Refractive surgery can now do the same thing. Most patients with up to six diopters of hyperopia can expect a very predictable outcome from refractive surgery. Your local eye surgeon can discuss which specific procedure will work best for you.

A quick word about your local eye surgeon. It's exciting to hear about all the new technology involving vision correction. Having said that, nothing beats the knowledge and experience of your local surgeon. She may not own the latest surgical laser, however her experience will likely achieve the same or better results than some newfangled device with which some newcomer has little experience.

Bottom line: patients should select surgeons they trust and not worry about the gadgets. Let the doctor worry about the gadgets, while keeping your best vision a priority.

Which foods are good for eye health?

You've made the important connection between vision and nutrition. In order to have healthy eyes, you need to be an ACE. That's an easy way to remember to consume plenty of vitamin A, vitamin C, and vitamin E every day. These are the "vision vitamins." They work to ensure healthy blood flow to the eyes, a healthy surface to the cornea by means of an enriched tear film and their antioxidant qualities preserve the very delicate tissues inside the eye. A balanced diet rich in fruits and vegetables will take care of business. If you choose to add supplements, look for daily multivitamins that meet the recommended daily allowances for vitamin A, vitamin C, and vitamin E. If you're going to the store to buy vitamins, then choose a brand that also includes valuable antioxidants, like beta carotene and lutein. The literature is confusing regarding proven benefits of dietary modifications to preserve healthy vision. It might take another 20 years to verify the value of nutritional supplements, but why wait?

How difficult would it be to switch from soft lenses to rigid lenses, in your experience?

This is a flip-flop question. Most of the time people ask the opposite, "How do I get from rigid lenses to soft lenses?"

Soft contact lenses are very comfortable but will not fully correct for excessive curvature in the cornea. We call that astigmatism. On the other hand, rigid, so-called hard contact lenses do a marvelous job eliminating astigmatism. However, patients report a more difficult time adjusting to the feel of rigid lenses. By the way, when we talk about rigid lenses, we typically mean gas-permeable contact lenses. These rigid lenses are made of a polymer that enhances the delivery of oxygen to the cornea.

If you say that your prescribing eye doctor wants to convert you from rigid to soft lenses, then you are in for a wonderful experience. Assuming the quality of vision is comparable, you will be delighted at how comfortable soft contact lenses are and how easy they are to maintain. You might even consider daily disposable soft contact lenses so you can forget about daily lens cleaning all together. For those of you counting your pennies, over a 90-day period, the out-of- pocket expense for rigid contact lenses, ordinary soft contact lenses and daily disposable lenses are roughly equivalent when you factor in cleaning supplies, lens storage cases, and replacement cost.

"Trauma is the leading cause of lost vision in adult males. Every day I encounter patients -- particularly young men -- who sustain preventable eye injuries."

What can a glaucoma patient do five years after a trabeculoplasty when IOP starts climbing again?

Let's first help other visitors understand your situation. There are many different types of glaucoma. In your case, your surgeon decided the best way to keep your intraocular pressure at a healthy level was by creating a new drain to permit fluid to leave the eye. Your surgeon decided the best way to control your intraocular pressure was to improve the performance of the "drain" by performing a laser procedure called a trabeculoplasty. Your experience is common. Trabeculoplasty often has a time-limited benefit. After five years or so, the drain's function begins to degrade. Every patient is different. Some patients can benefit from a modified repeat procedure.

Other patients are advised to undergo a traditional surgical procedure called trabeculectomy. This is essentially a tunnel that is created to provide a new pathway for fluid to leave the eye. To improve the chances for long-term pressure control, the surgeon may insert a sterile tube into the new drain (called a seton) that will help keep the drain open for years to come.

Do not be disappointed with your current situation. It is very common and experienced glaucoma specialists know exactly what to do to re-establish control over your intraocular pressure. Remember, you can contact me any time on the WebMD Message Board to discuss your situation further. Good luck!

My boyfriend had a car battery blow up in his eyes. He has lost all vision in his right eye due to two horseshoe-shaped scars from a laser. Is there any procedure being studied to reverse the loss of vision for damaged retinas?

You raise several important issues. Trauma is the leading cause of lost vision in adult males. Every day I encounter patients -- particularly young men -- who sustain preventable eye injuries. My point here is not to lecture you, but to make everyone else aware of the enormity of this problem. What this world needs are more safety goggles! Car manufacturers should probably affix a pair of polycarbonate goggles underneath the hood of their cars so that weekend mechanics can protect themselves. Manufacturers of powered yard tools, like weed trimmers, should sell their gear with goggles chained to the equipment. Perhaps that way they will use the goggles more often.

Regarding the specifics of your boyfriend's injury, if, as you say, he has sustained a tear in the retina that was lasered, then it suggests that the retina had not yet detached. That is very good news. The laser treatment will stimulate a scar to anchor that small retinal tear to the wall of the eye. A retinal tear by itself should not cause any significant drop in vision unless a nearby blood vessel burst. That kind of bleeding can be expected to totally clear over the next few weeks.

I'm wondering if some of your boyfriend's vision loss is related to battery acid. A toxic splash to the cornea can significantly damage the eyesight; however, the eye is very good at buffering acid to protect the eye, and this kind of injury should eventually heal over time. That's very different than an alkali splash (as happens in plumbing accidents) where permanent devastating damage to the eye can occur.

We wish your boyfriend a prompt recovery.

What safety precautions should be taken if you are going to be active in sports like baseball and swimming? And what precautions should be taken if you are going be spending a lot of time out in the bright sun? Are sunglasses necessary? What should we be looking for in sunglasses? I don't need regular glasses.

I could not have asked for a more informative question. Sports-related eye injuries represent a national epidemic. In fact, the American Academy of Ophthalmologists is recruiting all of its members to photograph and track all of the injuries seen by athletes so that we can accurately portray this problem with real statistics and real stories. Any athlete involved in contact sports or sports like baseball that involves hard, fast-moving objects, ought to have eye protection. Polycarbonate goggles are a superior choice because they are virtually indestructible. They can be clear or tinted. Baseball batters need to wear proper batter's helmets to protect not only the eye, but the surrounding bony structures, as well. Coaches and personal trainers can give specific recommendations for whatever individual activity you choose to participate in.

A quick precaution to patients who have had LASIK refractive surgery: Take extra care when involved in sports like water skiing. Yes, folks who have gone water skiing have damaged their LASIK flap when their face was struck by a strong spray of water. Consider wearing swim goggles while water skiing if you have had LASIK.

You also mentioned swimming. Swim goggles are also recommended. It's impossible for you to check the chemical composition of every pool, so you never really know what you are diving into. Slight changes in pH can dramatically change your vision because swelling can occur in the cornea. Quality swim goggles will protect you from this possible problem.

The evidence is mounting that lifetime sun damage jeopardizes the health of the eyes. Cataracts and macular degeneration are two such examples. We believe the damage comes from harmful ultraviolet light. It is helpful to choose eyewear that includes a UVA and UVB protection. Don't pay extra for ordinary spectacles to have UVA/UVB coatings. These UV coatings are already in the lenses' materials. Simple sunglasses change the color of visible light but still let the light in. Sun filter lenses actually block the transmission of specific light wavelengths.

So in summary, wear protective eyewear whenever involved in vigorous athletics or extreme sporting activities, and choose sun protection that guards against UVA and UVB radiation. Don't forget to frequently apply sunscreen lotions, as well.

"With summer vacation coming, parents need to pay extra attention to their children's vision needs. This is a wonderful time to have your children's eyes examined before the new school year begins."

Two of my children have nonaccommodative esotropia for which they wear glasses. If they do not grow out of it what are the chances LASIK will provide correction later in life? And why are contacts not recommended for their condition once they reach their teens?

For the sake of other visitors, esotropia is an eye muscle imbalance that causes the eyes to turn inward. Sometimes the eyes turn in because of refractive problems that force the eye to borrow accommodation (near focusing) to see clearly. Accommodation automatically causes the eye to turn inward, just like when we read.

In your situation, however, you report that your children are esotropic, but it is unrelated to their refractive error. That would suggest that the children's eyes are turning in whether or not they are wearing their glasses. If that is the case, it is not likely that the eyes will realign or become straight without the help of eye muscle surgery. That's different from accommodative esotropia, wherein eye glasses straighten the eyes.

Years from now if the children's eyes remain straight, they may be good candidates for refractive surgery. Who knows what will be available in 2015. Eye surgeons practicing in 2015 will likely laugh at what we are doing today, just like we giggle at the earliest procedures performed a generation ago. I predict that innovative technology will be available to help your children see clearly when the time is right. For now, the best you can do is to make sure that everything is done to help your children's eyes to work together.

Dr. Lloyd, we are almost out of time. Before we wrap things up for today, do you have any final words for us?

With summer vacation coming, parents need to pay extra attention to their children's vision needs. This is a wonderful time to have your children's eyes examined before the new school year begins. Don't forget to use protective eyewear whenever you're involved in yard work or eye-risky activity. And finally, don't let me catch any of you playing with fireworks! We'll talk again soon. Thank you.

Our thanks to Bill Lloyd, MD, for joining us today. Members, thanks for all of your great questions. I'm sorry we couldn't get to all of them.

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