Your eye is as dirty as your mouth.  The bacteria found on the eyeball and in the nose and mouth are very similar.  The three areas are all connected anatomically and bacteria are free to roam to and fro.  While each organ does have its own particular defense system to fight infection, the eye, by no means is “clean.”

It’s Why Your Nose Runs When You Cry

When you cry, you need to blow your nose.  When you use ophthalmic drops, you get a funny taste in your mouth.  The reason?  The tears drain right into your nose, or rather, your nasal cavity.

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The Anatomical Pathway of the Tears to Your Nose

a.  Lacrimal gland – resides in the upper/outer portion of the upper eyelid

b/e.  Punctum (“tear duct”) – small pinpoint openings on upper and lower lids, near your nose

c/f.  Canaliculus – connect each puncta to the lacrimal sac

d.  Lacrimal sac – internal collection point of the tears, located on the side of your nose, just below the bridge

g.  Nasolacrimal duct – connects the lacrimal sac to the internal portion of your nasal cavity, tears empty here.

That’s proof that the two areas are connected.  Bacteria can travel in the reverse direction.

There are Two Ways to Clear Your Nose

One of the more common ways to clear your nose is by using a tissue.  The other method, preferred by all boys in the Wong household, is the reverse of blowing your nose.

The “suck” method avoids the use of the tissue and allows internal disposal of the secretions by…um, well swallowing.

My point?  It demonstrates a clear connections between nose, mouth and ….eye.

What Does This Mean?

There are a few  practical advantages to now admitting that your eye is dirty.  It helps me guide my patients with respect to their post-operative care.

First, after retinal surgery, there are always concerns about washing hair and taking a shower.  What happens if water gets in my eye?  After a reminder that the three structures are all connected, it is clear that getting water in your eye during bathing is probably pretty safe (check with your own doctor for his opinion, please).

Also, there is a fear that something may get into your eye while at work.  Remember, your eye is as clean as your nose and mouth!

Mother nature has also supplied the eye with a few ways to fight infection.  Within the tears are lysozyme, immunoglobulin and lysin – all natural elements that combat bacteria and other foreign agents.

In addition, we also recommend antibiotic drops.

So, while your eye may have the potential to be laden with dirty organisms from your nose and mouth, it is unlikely you will get anything in there that is…dirtier.  If in fact you do, mother nature and your antibiotic drops are there just in case!

“Randy”

Randall V. Wong, M.D.

Ophthalmologist, Retina Specialist
Fairfax, Virginia

Diabetic retinopathy can blind.  Patients recently diagnosed with diabetes have a lot to learn about their eyes.  Regardless if patients are Type I or Type II diabetics, there is a short check list to learn to ensure proper care for their eyes.

Blurry Vision is Normal

At first, the blurry vision is to be expected and should become more consistent as your sugar levels become stable.

It’s hard to know exactly how long you have been diabetic.  It is quite likely your vision was fine, but since you’ve been diagnosed, your glasses don’t work and your vision is blurry.

Sugar levels affect the strength of glasses that we need.  For instance, let’s say you got glasses and your sugar was 150.  Two weeks later they arrive and your sugar has been 350. Your glasses/contacts won’t work.

Large fluctuations in your sugar cause changes in the prescription. This phenomenon is related to the fact that the water content of your natural lens changes with fluctuations of your sugar.

See Your Eye Doctor After Your Sugar is Controlled

Blurry vision or not, it is recommended that every diabetic get a full, dilated eye exam at the time of diagnosis, not only for possible glasses, but to look for pre-existing diabetic retinopathy.

I would recommend that you see your eye doctor after your sugar is controlled and has been controlled for several weeks. There is a lag time between changes in your sugar and the water content in the lens of your eye.

Every Diabetic Patient Needs an Exam At Least Once a Year

As recommended by the American Academy of Ophthalmology, the American Optometric Association and the American Diabetes Association every diabetic patient needs to be examined, at the minimum, once per year.

This does not mean a glasses check, but a full dilated eye exam allowing your doctor to examine your retina.

Good Vision Does Not Mean No Disease

There is no correlation between your vision and the presence, or absence, of diabetic retinopathy.

For instance, patients can have perfect, 20/20, vision and still be on the verge of blindness or loss of vision.  The only way to determine any active retinopathy is for your doctor to see you.

You are NOT Going to go Blind

If you are examined regularly, the chance of severe vision loss, including blindness, is < 0.3%.  That’s right, timely, regular eye exams will allow your doctors to diagnose, treat, and prevent severe vision loss from diabetic retinopathy.  We are best able to prevent vision than we are at restoring vision.

What Does This Mean? These are great starting points for anyone newly diagnosed with diabetes.  Pass these simple tips on to someone you know that is newly diagnosed.

There is a lot going on with a new diagnosis of diabetes and good clear information about diabetic retinopathy should help take some of the anxiety away about their new diagnosis.

“Randy”

Randall V. Wong, M.D.

Ophthalmologist, Retina Specialist
Fairfax, Virginia

Glaucoma is a disease that can lead to blindness by destroying the optic nerve.  There is an increased risk in developing glaucoma if you have diabetic retinopathy.  I am not aware of such a risk with macular degeneration.

“Open Angle Glaucoma” is the Most Common for in the U.S.

There are many types of glaucoma, but most common in the U.S. is “open angle” glaucoma.  All the structures of the eye are normal, yet there tends to be an elevated eye pressure associated with typical glaucomatous nerve damage.  Most treatments are aimed at lowering the eye pressure with drops.  In many cases this may be an adequate way to slow down, or control the disease.

Risk factor for developing open angle glaucoma includes race (especially blacks/african american), family history, increasing age and steroid users.

There is mild increased chance of developing open angle glaucoma with …diabetes.

There are generally NO symptoms with open angle glaucoma.  It is painless and destroys optic nerve tissue very, very slowly.

During almost any exam, however, your doctor generally checks your intraocular pressure, or, IOP.  Glaucoma is not a cut and dry diagnosis, but higher than normal pressures probably warrant a glaucoma evaluation.

Neovascular Glaucoma Hurts and Blinds

Neovascular glaucoma can develop in patients with proliferative diabetic retinopathy.  By definition, patients with proliferative diabetic retinopathy have neovascularization (abnormal blood vessels) growing on the surface of the retina or on other structures.   If  you recall, the neovascularization cause a diabetic retinal detachment, vitreous hemorrhage and neovascular glaucoma.

At times, the abnormal blood vessels, the neovascular blood vessels, can grow over the “angle” of the eye.  The “angle” is a specific area in the front of  the eye and it is the only area that provides drainage to the interior of the eye.

The eye pressure can rise significantly if the “angle” becomes closed, or clogged, with neovascular tissue.  The pressure can cause severe redness, headache, nausea and pain.  Pressures can be 3-4x normal!  At these pressures, permanent vision loss, including blindness can occur rapidly.

Treatment for Neovascular Glaucoma Includes Laser

The same laser treatment, namely panretinal photocoagulation (PRP), used to treat proliferative diabetic retinopathy is the preferred treatment for neovascular glaucoma (NVG).  The mechanism of the disease is still the same.

Vascular Endothelial Growth Factor (VEGF) is liberated in response to insufficient oxygen supply.  The VEGF causes the blood vessels to form on the retinal surface and the “angle.”

While the real “fix” is PRP, temporary improvements may be possible with intermitten anti-VEGF medications.  At this time; however, it appears as though the anti-VEGF injections, such as Avastin, Lucentis or Macugen need to be repeated.  In most cases, the laser treatment does not need to be repeated.

What Does This Mean? This is the second way a patient with proliferative diabetic retinopathy can go blind.  Patients that develop retinal detachments from diabetic retinopathy can also go blond.   Uncontrolled neovascular glaucoma is a late complication of only proliferative diabetic retinopathy.

It does not occur in the more common, non-proliferative phase of the disease.

While diabetics are at risk for developing “open-angle” glaucoma, your doctor should be monitoring you for that anyway by taking your IOP everytime you reach the office.   Part of your retinal exam should also entail looking for signs of the proliferative disease as well.

“Randy”

Randall V. Wong, M.D.

Ophthalmologist, Retina Specialist
Fairfax, Virginia

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“Mr. Ozurdex” is a patient in whom I injected Ozurdex® for the treatment of a branch retinal vein occlusion (BRVO).  Ozurdex, is the first sustained release drug delivery system for the eye.  It was FDA approved for the treatment of retinal vein occlusions last summer (RVO).  Allergan began marketing Ozurdex shortly after the FDA approval.

Mr. Ozurdex was given an intraocular injection in early January.  Upon his first return visit, he noted a dramatic improvement in his vision!  At the time of injection, he was legally blind.  After only 2 weeks, his vision improved enough to read.

Upon his return this week, his vision remains stable, he can still read and there are no concerns of any complications.  As with any injection of steroid, in increase in eye pressure may occur.  Happily, there is none.

Mrs. Ozurdex is Still Worried

“Mrs. Ozurdex,” on the other hand, is still not seeing any differently.  About the same time, I injected Ozurdex for treatment of a central retinal vein occlusion (CRVO). There are two types of retinal vein occlusions; central (CRVO) and branch (BRVO).

Mr. “O” had a BRVO.  The visual prognosis has always been better with a branch retinal vein occlusion.

Mrs. “O” had a CRVO.  The visual prognosis has always been much poorer with a central retinal vein occlusion.

Early Visual Results May be Misleading

I have cautioned both patients.  First, with Mr. Ozurdex, while the results are fantastic, the real question is whether or not we can sustain this improvement.  He may require another injection of Ozurdex, plain steroid, or even anti-VEGF, such as Avastin.

I have encouraged Mrs. Ozurdex to remain positive.  First, she is no worse than when we decided on the sustained release therapy, and second, the drug will be released for several more months to come.  There is still a great deal of blood and edema that can resolve, so who is to say how well she’ll fare over the next four months?

What Does This Mean? It is exciting to try a new therapy especially in an area where there have traditionally been few therapeutic options.  It is also easy to be biased, good or bad, about the results of a new treatment.

I have no way of really knowing if every patient is going to respond like Mr. “O.”  We have yet to define the perfect patient for receiving the new steroid releasing device, perhaps everyone will.

It’s too early to tell if Mrs. “O” is exhibiting a typical or atypical response to Ozurdex given her condition.

Though the FDA has given its approval, it doesn’t necessarily translate into a positive outcome.

Surgical outcomes are never guaranteed, there are risks to surgery.  In fact, nothing in medicine is guaranteed.  One role of doctors is to educate about the benefits and potential risks of a treatment.  On the other hand, if an operation, were successful every time, would we need doctors?

Starting Your Car is Guaranteed

Each time you turn the ignition, your car starts.  It is just about guaranteed.  The outcome is so successful, we have lost an understanding of automobile mechanics (yet in doing so we have become pretty sophisticated in understanding car warranties).  When you buy a car, do you ever question how often the car will start?

Eye Surgery Works Like a Car

Now let’s turn to surgical outcomes.  What if eye surgery were successful each and every time?  By successful I mean each patient saw better immediately after surgery and there were no complications from the surgery.  Each surgical outcome was successful.

If eye surgery were as successful as a car starting; we wouldn’t need discussions about possible complications of surgery, nor would we need counseling about possible visual outcomes after surgery.

Eye surgery would be risk free.  There would be benefits and no need to counsel about possible risks.  Would we need docs?

Cataract Surgery is Intuitive and Highly Successful

The technical complication rate of cataract surgery is somewhere around < 0.1%, that is, rarely are there problems with removing a cataract and inserting an implant.  Visual outcomes in cataract are very high and, for the sake of this article, most patients see better after cataract surgery.

Cataract surgery is also intuitive.  You have an operation and you see better.   “Successful” cataract surgery means improved vsion.

There Are No Blogs About Cataract Surgery

Patients with retinal disease, such as diabetic reitnopathy and macular degeneration, have non-intuitive eye problems.  There are fairly complex discussions that each individual must face.  Hence, the success of this blog is based upon the complexity and confusion of having retinal disease.

Cataract surgery, by comparison, has far fewer variables and takes less understanding.  It takes less counseling.  There aren’t many reasons to have a web-based information site, because almost all the time, surgery is “successful.”

What Does This Mean? I say this all the time.  “If something were successful all of the time, a doctor would never have to speak to a patient.”

Cataract surgery and retinal disease are at opposite ends of the spectrum.  Chances are you know more about cataract surgery than you do about retinal disease.

Retinal disease is pretty complex, the vision is often compromised and the surgical outcomes are somewhat “blurry.”

It is pretty disheartening for a patient to undergo a retinal operation, eye injections, laser, etc. and be left with decreased vision, yet the procedure has been deemed “successful.”

Keeping a patient’s perspective optimistic despite vision loss can be trying.  I have found the best way for patients to accept their outcomes is by giving them truthful knowledge, and if we are lucky, an understanding about their disease.  Hence, a reason for this blog.

“Randy”

Randall V. Wong, M.D.

Ophthalmologist, Retina Specialist
Fairfax, Virginia

What if there were eye drops for treating your macular degeneration?  What if all you had to do was simply use a few drops a day and your vision would get better?  There is a “solution” for tired eyes, redness, contact lenses, but what about for your retina?

Eye Drops for Macular Degeneration Sound Compelling

There aren’t any eye drops for macular degeneration or diabetic retinopathy.  In fact there are few retinal diseases where they would work at all.  Topical drops, just like intravitreal injections, however, are great because the medicine is placed directly where you want it – at the target tissue.

Drops, like eyeglasses, seem to be a panacea.  No matter how carefully I explain the prognosis or treatment plan to a patient, I usually get a blank stare (and then I realize noone was listening to me) and then they say the inevitable…”What about eye drops?” or “What about Glasses?”

“Visine” – It Gets the Red Out

Maybe the reason eye drops are held so closely to everyone’s heart is due to “Visine®,” or at least the marketing department of Visine.  Everyone knows that famous byline – “it gets the red out.”

A drop that gets red, tired eyes to look refreshed in seconds certainly would get my attention.  If there are drops that get your eyes to change appearance, then there must be drops for everything else…right?

Most Drops Work Only on the Outside

There are ocular solutions for;

• redness
• allergy and itching
• infections
• dryness (artificial tears)
• glaucoma
• dilating drops
• and for inflammation.

But there are no drops for macular degeneration or diabetic retinopathy for that matter.  Eye drops are great for diseases that affect the outside of the eye.  So called “topical therapy”  typically does not penetrate the eye very well, and it is very difficult to get any significant concentration of drug into the vitreous or to the retina.

Outside of glaucoma, most drops are placed exactly where we want them, on the outside of the eye.  Glaucoma drugs have become pretty good (so I’m told) at lowering the pressure inside the eye due to limited penetration of the glaucoma drug.

Most Drugs Never Get Inside the Eye

May be now this makes a bit more sense.  Eye drops for macular degeneration sound great, but they just don’t exist.  As far as we can tell, we have found the right drugs, but not in a form that has easy an easy time getting to the inside of the eye.  Avastin®, Macugen® and Lucentis® are all too large for the molecules to penetrate the ocular surface.  Steroids, such as Kenalog® or related anti-inflammatory agents, have poor surface penetration, too.  All these drugs, if given as topical eye drops, would simply splash on your eye and run down your cheek…wasted.

What Does This Mean? My comments a few weeks ago about the blood brain barrier and the treatment of retinal disease left out any remarks about topical treatments.  Eye drops are great for diseases on the outside of the eye.  Just as intravitreal injections are working well for retinal disease due to targeted delivery, so too are eye drops.  They are delivered directly to the target issue.

In eye disease, we do have to split hairs.  There are vast differences between the outside and inside of the eye.  The method we choose to deliver the drugs depends upon what, and where, you are treating.

“Randy”

Randall V. Wong, M.D.

Ophthalmologist, Retina Specialist
Fairfax, Virginia

Good morning!  I have made some executive changes (at a nominal cost) to improve the layout and navigation of the web page!  While the content should be the exactly the same, I have finally made some long awaited to changes to make this  a more valuable resource for patients with Macular Degeneration and Diabetic Retinopathy.

Some of the improvements;

Navigation Bar – you’ll notice more friendly “tabs” to direct you to the cornerstone pages of the site.  For instance, clicking on “Diabetes & Eye” will take you to a general overview of the disease.

Wider Columns - I am playing around with the number and layout of the columns to allow a larger reading area and make each article less choppy.

Categories – I will be reducing the number of categories by getting rid of some of the redundant headings.

Tags - are the keywords that pertain to each article.  You will find them at the bottom of each post.  If want to find more information about a similar topic…simply click the keyword that attracts you.

Have fun!

“Randy”

Randall V. Wong, M.D.
Ophthalmologist, Retina Specialist
Fairfax, Virginia

Cataract surgery is needed when your vision is not as good as you’d like, and, your eye doctor feels that the surgery would help.  In cases of diabetic retinopathy and macular degeneration, there may be other factors that weigh in to the decision of having cataract surgery.

Cataracts are usually elective surgery.  While insurance does cover most cataract surgery, there are a few criteria for having the surgery done.  Most of the criteria are based on certain vision measurements taken at your eye doctor’s office.  Your visual acuity, with or without glasses, may simply be bad enough to qualify you for surgery.  Sometimes your daylight vision is fine, but you may suffer from significant glare when driving at night with oncoming headlights.  In addition to vision, your doctor simply needs to affirm the presence of a cataract and likelihood of improvement with surgery.

There is no hurry to having surgery.  Unlike a piece of overripe fruit, you really have lots of time.  Choose a time when you are ready for surgery and is convenient for the rest of your friends or family; whoever may be helping you.

There is no strain on the other eye.  Don’t worry about overworking the other eye while waiting for cataract surgery.  There really is not such thing.

Patients with diabetes have some additional concerns regarding the timing of cataract surgery.  If you have a history of diabetic retinopathy, make sure that the diabetic retinopathy is stable at the time of surgery.  The only way to assess stability is with a dilated eye exam with your doctor or retina specialist.

While the timing is not that crucial in cases of macular degeneration, the expectations of cataract surgery should be reviewed with the doctor.  By definition, patients with macular degeneration already have decreased vision from their retinal disease.  Make sure you and your doctor are on par with your expectations after surgery.

What Does This Mean? Cataract surgery can be a life changing event.  In most cases, there is likely to be full restoration of vision.  The timing of cataract surgery is basically up to you, based upon your own tolerance, or intolerance, of blurry vision.

If you have cataracts, or suspect that you do, I would recommend an examination soon with your eye doctor.  Use this visit as a fact finding mission, you’ll be surprised how much there is to learn about cataract surgery.  You don’t have to commit to surgery.

Take your time to schedule the surgery.  Make sure you are ready.

If you have retinal disease, such as diabetic retinopathy or macular degeneration, make sure you and your doctor are “on the same page” about the timing and expectations of the surgery.

“Randy”

Randall V. Wong, M.D.

Retina Specialist, Ophthalmologist
Fairfax, Virginia

Most of the time I write about information about regarding macular degeneration and diabetic retinopathy.  As many of you remember, I am very interested in persuading more docs to do the same, that is, provide credible health information on the Internet.

An article in Reuter’s claims that over 50% of Americans turned to the Internet for health information last year.  Way to go!  At the same time, fewer than 5% ever bothered to email their own doctor.

As more and more people are turning to the Internet for health information, I am hopeful more and more doctors will meet you there by providing solid, credible health information.

Docs are resistant to using the Internet.  There are misgivings at several layers.  Basically, docs don’t want to give away their expertise and are afraid of getting sued by offering medical advice that may be… well, wrong.  But they don’t have to give away advice as patients are looking for information…not opinion.

The difference between information and advice is that information is factual.  Advice is an opinion.   Doctors get information and advice mixed up.  I believe patients search the Internet for health information for the same reason we want to know about world news…they just want to know.  They want information about a disease or sickness.

People crave information.  The single biggest activity that occurs everyday on the Internet is “search.”  People are constantly searching, or “Googling,” for information.  But I don’t think patients are looking for advice.

Clinical judgment is what keeps doctors special.  Clinical judgment arises as a result of melding together facts with patient experience.  I support doctors publishing facts.  Clinical judgment entails an exam that can NOT be facilitated over the Internet…ergo, there should be nothing to fear.

Clinical judgment does not exist on the Internet, it will always be what keeps a doctor “unique.”

What Does This Mean? This means that doctors, and other health authorities, really should feel free to publish credible health information.  Information does not mean you are giving advice, opinion or treatment.  There really aren’t any liability issues.

From a public health perspective, the more good information on the web, the more likely someone will seek medical attention.

This web site is intended to be a single source of information about diabetic retinopathy and macular degeneration.  There should be more like it.  There is no abuse.

“Randy”

Randall V. Wong, M.D.

Ophthalmologist, Retina Specialist
Fairfax, Virginia

Dilating drops are useful tools for examining the eye.  Direct visualization is the best way to examine the retina and is second to none.  The dilating drops are annoying, but are necessary.  Any and every time your doctor needs to look at your retina, you should be dilated.

Dilating drops cause mydriasis (pupillary dilation).  They really have no medicinal purpose, though in certain types of inflammation, they may relieve pain.  Atropine, or bella donna, was used in ancient times to dilate the pupils as a way to accentuate beauty.  In modern times, atropine, or atropine-like medicines, are used to facilitate retinal examination, paralyze focusing ability and allow intraocular surgery.-

Retinal examination for conditions such as diabetic retinopathy and macular degeneration should be performed regularly.  The best, cheapest and most efficient way to exam treat these disease is by looking directly at the retina.  Two types of drops are usually used to effectively dilate the pupil.  Actually, the “pupil” is the opening in the iris.  One drop activates a muscle (alpha-adrenergic muscles) that runs radially (like spokes on a wheel) on the iris.  A second drop, inhibits constriction of a circular muscle (it closes the pupil like a purse-string) on the edge of the iris, thereby allowing dilation to occur, that is, in normally opposes the action of the radial muscle.

With a widely dilated pupil, a cataract can be properly identified, the optic nerve inspected for disease such as glaucoma, the retinal veins and arteries are revealed, not to mention detailed examination of the macula and peripheral retina.

Paralysis of Focusing Muscles is a secondary effect of complete dilation.  This is called “cycloplegia.”  The muscles that contract to reshape our natural lens allowing focusing for reading (and focusing at distance for far-sighted people) are paralyzed.  This wipes out close range focusing and distance focusing (for far-sighted people only).

For children, who are usually farsighted at a young age, this is an important step in properly measuring for glasses.  As the eye gets bigger, we become more near-sighted (or less far-sighted).  Thus, most average kids are farsighted and don’t need glasses in most cases.  To properly measure far-sightedness, however,  especially in a kid, the muscles need to be paralyzed.

For adults, this a very annoying part of the dilated exam – there is too much light entering the pupil and everything is fuzzy!

In most cases of intraocular surgery, such as cataract surgery and retinal surgery (aka vitrectomy), the pupil must be widely dilated to see and operate.  Pre-operatively, the same drops are given to dilate the iris/pupil at the operating room as used in the office.  The dilation can last for hours which should be enough time to get the operation done.

What Does This Mean? Dilating the eye is important because the most important structures of the eye; lens, optic nerve and retina, can only be examined by looking directly at them.  Every time a retinal examination is anticipated you should dilated.  Some docs are using non-mydriatic (aka non-dilating) equipment to see in the eye, but these devices are designed for screening purposes and are not considered detailed enough to allow a diagnostic exam.  The point is…get dilated.

There used to be drops that reverse dilation, but I haven’t seen them in a few years.  They are expensive to use and are uncomfortable for the patient.

“Randy”

Randall V. Wong, M.D.

Retina Specialist, Ophthalmologist
Fairfax, Virginia