Aging Eyes, Youthful Vision-- Bill Lloyd, MD-- 03/09/04

Last Editorial Review: 10/19/2004

By Bill Lloyd
WebMD Live Events Transcript

We are getting older and so are our eyes. But today there are more ways to effectively manage failing vision, and not everyone needs surgery. We brought our vision questions to WebMD's eye guy, ophthalmologist Bill Lloyd, MD.

The opinions expressed herein are the guest's 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.

Moderator: Welcome, once again, Dr. Lloyd. Thanks for being our guest for this Live Event.

Lloyd: Thanks for inviting me. As adults approach "middle age" it seems visual symptoms are the very earliest changes that reminds them time is marching on. Let's spend some time today talking about those healthy changes that occur in everyone's eyes and what we can do to help ourselves see better throughout our lives.

Moderator: Let's look at some of those visual changes. Here's our first question:

Member question: My husband will be 73 this year. He has diabetes with good control and high blood pressure. I have noticed that he consistently veers to the left when driving, day or night. He often goes over the lane stripes and does not seem to be aware of this until a car approaches going the opposite way. More often at night he slows down before traffic light intersections. Saturday evening he actually stopped at a green light. He also tried to turn onto a street, which he mistook for an interstate ramp and then missed a marked ramp. Is there any way an ophthalmologist can test a person's ability to see at night vs. daytime? Or are there other issues that should be explored to evaluate the situation objectively?

This is a very familiar situation. People value their driver's license and the freedom that comes with driving. The thought of surrendering driving privileges (and it is a privilege, not a right) signals loss of independence. That's why many older adults are extremely hesitant to do anything that might jeopardize their ability to drive. This includes a routine eye examination! You've raised many important issues.

Let's talk about vision first. By the age of 73, any adult has already started developing significant cloudiness in the lens of each eye. We call that a cataract. Cataracts are universal. There are many different kinds of cataracts. Some cataracts permit the individual to read comfortably, get around well during daylight, but wipe out vision in dimly lit environments. Your local eye doctor can quickly determine if your husband has the kind of cataract that would interfere with safe driving.

By the way, cataract surgery is the most commonly performed operation in America, and the success rate is extremely high.

Decision-making while driving can be very difficult for older adults. They are bombarded by many different stimuli and it can be a very confusing experience, both for the driver and the passenger. Don't forget, you have options, too. It may be time for an intervention, wherein you and your family and perhaps the doctor confront your husband about this dangerous problem. Do not schedule an intervention unless you are prepared to abandon riding in the car with him. That is to say, if there are no consequences, the intervention is worthless.

Hopefully, this encounter will serve as a valuable wake-up call for your husband to make sure there are no underlying medical or neurologic problems that keep him from being a safe driver.

Member question:
I would like to know when a cataract is ready to be removed.

Lloyd: This is one of the most common questions I am asked in clinical practice. Nowadays, cataract surgery can be performed at any time. This represents an enormous change from just a generation ago. Let me explain. As recently as 1960, one-third of patients who underwent cataract extraction ended up with worse eyesight! You can understand why people were extremely reluctant to have the operation. Since that time, innovations in surgical instruments and techniques now permit safe cataract extraction in patients of all ages. 

The current recommendation for timing cataract surgery is when the patient can no longer tolerate the cataract symptoms (blurriness, glare, halos, etc.). Prior to surgery the eye doctor will make sure the eye is otherwise healthy. These days, eye surgeons can test what the postoperative vision will be BEFORE cataract extraction is performed. They have a device that "burns" through the cataract to test the functioning of the retina. This offers patients a high degree of confidence as they approach surgery, knowing they can expect a good outcome.

Member question:
My glasses have become so scratched that it makes them hard to see through; everything looks cloudy. It is as if they are really dirty, but no amount of cleaning will clear them. While I'm saving up for new glasses (blended lenses aren't covered under my insurance plan), is it better to use the scratched lenses or can I use my old glasses? They give me a headache and eye ache but aren't scratched and cloudy. I work on a computer all day and really need glasses to do my work.

You have painted yourself into a nice corner. The problem with scratches on the lens is that each scratch distorts the incoming visual rays. Each scratch, therefore, acts like a tiny prism. Regarding your old glasses, the fact that wearing them causes headaches indicates the refractive power of those old spectacles is inadequate for your current needs.

Here are some solutions. You can ask your eye doctor for a single prescription to be used only at the computer. Using coupons in the Sunday paper, you probably will be able to find a discount on a single view prescription for $50 or less. These new glasses will only be worn while working at the computer -- your primary visual requirement.

I would recommend wearing the scratched lenses over the older glasses (versus no glasses!) until you can afford a more expensive pair. 

There are other solutions. If you are in financial trouble, you can seek help from civic organizations like the Lion's Club, who collect thousands of pairs of used, serviceable eyewear. They may have just what you need in the interim.

Member question: I have a macular pucker in my only good eye. Other than surgery is there another treatment?

Lloyd: Macular pucker is not a rare problem. The macula is the most critical portion of the retina. It is approximately the same size as the diameter of a pencil. All precise vision is processed at the macula. Having said that, if you lose your macula, you will experience a profound loss of vision. On the other hand, you can lose the remaining 99% of your retina, yet preserve your macula and function well.

Macular pucker is a problem caused by the clear vitreous gel that fills the healthy eye, much like water in a glass. Except, this vitreous gel is in a "tug of war" with a small patch of retina. Unfortunately, this small patch is the macula. Most patients with macular pucker do not require surgery, and the problem will resolve on its own over time. The vitreous traction dissolves. In some patients, however, traction persists and this is very unhealthy for the retina.

Certain tests are performed to determine whether or not surgery is advised. One standard claims that vision less than 20/80 justifies surgery. This information must be balanced in your case with the fact that this is your only seeing eye. You and your doctor must weigh the benefits, risks, and alternatives to surgery before moving forward.

Member question: Given that drusen is or may be a precursor of age-related macular degeneration, is there any way to reverse (or at least prevent the further accumulation) of drusen? Also, would such accumulation prevention or reversal of drusen presence reduce the probability of developing ARMD?

Lloyd: Age-related macular degeneration is the leading cause of permanent vision loss in adults over 55. Millions of Americans are affected by ARMD. Drusen refers to small crystal-like deposits underneath the retina that represent an early finding in ARMD. Most people with drusen continue to see very well.

A small percentage of ARMD patients progress and develop abnormal blood vessels underneath the retina. This is where the trouble starts. These new vessels leak and cause bleeding and scarring. This is what damages the eyesight in patients with advanced ARMD.

Nutritional supplements for ARMD are a hot topic. There have been many recent published studies in the medical literature on this subject. The largest study comes from the National Eye Institute. They found that nutritional supplements delay the development (or progression) of ARMD but do not reverse the condition. The most promising data about vitamins shows that 500 milligrams vitamin C, 400 IU vitamin E, 15 milligrams beta-carotene, and 80 milligrams of zinc daily, offer the best preventive step you can take to protect your retina. Other nutritional supplements are still being studied.

Member question: My eye doctor thinks I may have open-angle glaucoma, and I work on the computer 8 hours a day. Could that exacerbate the glaucoma?

Lloyd: Open angle glaucoma is by far the most common form of adult glaucoma. Here's what we mean by "open angle" glaucoma: The word 'angle' refers to the anatomic drain that permits fluid to leave the eye. Most people believe the eyeball is a closed tank of fluid. Nothing could be further from the truth! The eye is more like a runaway toilet, constantly producing and draining fluid throughout the day. Elevated pressure in the eye and subsequent eye damage (glaucoma) happens when there is an imbalance - either the eye is making too much fluid or the angle cannot drain the fluid fast enough. This is very different than closed angle glaucoma, where the pressure is due solely to a closed drain. 

Daily visual tasks do not interfere with fluid drainage, and this includes long hours at the computer. Most experts believe open-angle glaucoma can be traced to your DNA. Exciting research is underway that will unlock both the cause of glaucoma and new ways to prevent its damage.

In summary, continue to receive your routine eye checks, take all eye drops that are prescribed, and spend as much time as you want online with us here at WebMD.

Member question: Another question: Only my right eye seems to be affected. Is that unusual?

Lloyd: Most cases of open-angle glaucoma affect both eyes. Sometimes in the early stages of glaucoma one eye appears to be more affected than the other. Your eye doctor needs to be confident that the cause of elevated pressure is not due to some other treatable condition. Eye specialists have a short list of eye disorders that cause glaucoma in one eye only. You might want to confer with your eye doctor to discuss this situation further.

Member question: Dr. Lloyd, I was diagnosed with diabetes on 2/13/04. That day on I went on a low-carb diet (15-20 carbs/day) on the 14-15 day of diet I noticed a change in my vision, for the better. My vision was 20/400 it is now 20/30 and has remained the same for the last 12 days (I went to the optometrist yesterday to have it checked). My question is, is this a common occurrence? Can you share any experience with this you may have?

Lloyd: Your experience is very common among the diabetic population. The lens responds quickly to abrupt changes in blood glucose levels. Untreated diabetics typically have high levels of blood sugar. This interferes with the metabolism of the lens inside the eye, causing it to swell. The lens has a new shape and with it, different optical properties.

Once sugar levels are restored to normal (through medication or diet) the lens regains its original shape and optical properties. Voila! Blurry vision reversed by lowering abnormally high blood sugars.

Here's what's important to know: anyone who experiences frequent fluctuations in visual acuity, whether or not they need eyeglasses, should be suspicious that their blood sugar levels may be abnormal. If this situation occurs to you, see your family physician and consider the possibility of testing for diabetes.

Member question: I am 28 and already show early signs of glaucoma. What can I do, without medication, at this stage?

Lloyd: Twenty-eight sounds a bit early for glaucoma. Typically, problems don't start until the 40th birthday. Nevertheless, there are always exceptions. When you said "problems with glaucoma," perhaps you were simply referring to the measurement of your intraocular pressure. Most of the time eye doctors will measure the pressure during a routine examination. Remember, a single test is just like a snapshot; it only offers a brief glimpse into what is going on.

Did you know the pressure in the eye varies throughout the day? Just before sunrise it is normally at its highest levels. So, if a past eye exam was performed in the late afternoon and a follow-up exam was in the early morning, your records would probably show a "rise" of your intraocular pressure. That information, alone is insufficient to diagnose glaucoma. What you need now is accurate information. Visit with your eye doctor to clarify these issues. Are we simply following pressure measurements or has actual damage to the eye and optic nerve occurred?

In response to your specific question, there is no preventive treatment for development of glaucoma. The good news is there are numerous, powerful treatments for those who have been diagnosed. Once you have answers, visit us here at our Eye and Vision Disorder community to talk about what you've discovered.

Member question: I have MS and unclear vision -- not sharp ever. Is this just something I have to put up with?

Lloyd: Many patients with multiple sclerosis have vision problems. Many of the problems are, in fact, related to their MS, but just as many of these visual symptoms are related to other, treatable conditions that affect the general population.

The most commonly diagnosed vision problem related to MS is something called optic neuritis. Optic neuritis is inflammation of the "TV cable" that connects the eyeball to the brain. Most patients diagnosed with MS have periodic bouts of optic neuritis. 

In order to determine whether your blurriness is indeed related to your MS, or perhaps some other treatable situation (like needing new glasses) ask your primary care provider to schedule an appointment for you with an experienced eye specialist. As you know, it's important for all MS patients to build an open relationship with their eye doctor and neurologist. Open communication is essential; everyone needs to be on the same page. If your current doctors seem disinterested, then it may be time to build a new team.

Member question: If a person has had optic neuritis years ago but not since does it still show up?

Lloyd: Statistics regarding optic neuritis are controversial. Yes, it's true that some MS patients experience a single attack of optic neuritis and that's it. More often, however, MS patients experience periodic bouts of optic neuritis every several years. Not every patient with optic neuritis develops multiple sclerosis. In fact, in one of the largest studies, 60% of new onset optic neuritis patients NEVER developed MS.

Member question: I am 73 years old. My doctor has informed me my cataract is not fit for operation as yet. Is there some medicine or exercise to limit or reverse the process?

Lloyd: Just like we mentioned several minutes ago there are no nutritional supplements or dietary remedies that will halt or reverse cataract, just like they won't halt or reverse macular degeneration. Both of these conditions represent life-long changes that have developed over decades. 

There are ways to cope with the diagnosis of cataract until the doctor decides its time for surgery. Depending on your particular symptoms, you can make some simple adjustments to help see better:

  • Consider subscribing to large print newspapers and periodicals
  • Always wear protective eyewear when outdoors.
  • There are some special amber-colored sunglasses that help selected cataract patients see better when outdoors.
  • Many cataract patients struggle most in poorly lit environments. Make sure you leave a night light on during the evening in case you need to roam the house after bedtime.

Finally, if you know it is unsafe for you to drive, then make the mature decision to allow others to drive until you have completely recovered from your cataract surgery.

Member question: My optometrist just checked me and he prescribed only one contact lens for monovision. However, after a couple of months, I am seeing blurry. Could it be that I am using my "lens-less" eye too much? I am 53 and have used two lenses for monovision for more than five years. This change to one lens was recent.

Lloyd: Let's get other visitors up to speed. Monovision is a technique used by eye doctors to permit individuals to see at distance and at near without glasses. The eye doctor prescribes one contact lens for distance vision (typically worn over the dominant eye) and a different contact lens on the fellow eye for near tasks. The brain is able to discriminate when you are using the distant eye or the near eye without blurriness or double vision.

Since you report that your eye doctor has eliminated one of your contact lenses that shows a change in refraction regarding your distance vision. Perhaps you have started to develop the earliest cataract changes. Don't worry! At this stage, early cataract can actually help improve distance vision.

Having said all this, any time you experience blurriness, whether while wearing one contact lens, two contact lenses or no contact lenses, it's wise to get back to the prescribing doctor to discuss this situation.

Member question: My employers (a hospital system) have me working on a computer with forms that contain data that is extremely small (< 0.2mm and 57 lines per page). I have expressed concern about eyestrain and offered to re-design. How best can I approach this issue? Or do I just walk away from the job? I am in my late 60s. 

Lloyd: No one should be forced to work in an uncomfortable environment. Computer workstations represent the No. 1 source of work-related health complaints. Here are some ways that will help you see better and allow you to keep your job: Ask your network administrator for privileges that will allow you to change your settings at your workstation. This is an easy way to magnify what you see on the screen and to allow you to do your work comfortably.

The next option is a bit more expensive. Ask your employer if they would consider purchasing you a larger monitor. Once again the screen image can be enlarged by an external magnifying device that will permit you to view more of the document with excellent resolution.

Your individual circumstances are more troubling because of your age. This is not age discrimination; this is "focusing" discrimination. By age 60, your healthy eyes have lost nearly all of their accommodation. Nearly everyone at age 60 needs help seeing at near. By compounding matters by forcing you to work with miniscule text, your work situation becomes very complicated.

Frankly, I would save quitting as a final resort. Be sure to create a paper trail that documents what discussions you have had with management and what remedies you have proposed in order that you can continue to be a productive employee. Reasonable adults ought to be able to find a healthy compromise to this dilemma. Good luck.

Moderator: We are almost out of time. Before we wrap up for today, do you have any final comments for us, Dr. Lloyd?

Lloyd: For those aged 40 and older, don't forget to have your vision checked at least once a year, to include a pressure check. Most vision problems that affect adults over 40 are easily diagnosed and just as easy to manage. Protect your precious eyesight.

Moderator: Thanks to Bill Lloyd, MD, for being our guest.

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