Age Related Eye Disorders

1 Comment / John T. Rowe, MD / September 13, 2012

Presbyopia

An unwelcome harbinger of middle age, presbyopia is part of the natural process of growing old. Usually beginning by about the age of 45, presbyopia is the inability to focus the eyes on near objects and it gets progressively worse until about the age of 65. Presbyopia may be first noticed when it becomes necessary to hold objects farther away in order to see them clearly. The term presbyopia comes from the Greek presby meaning ‘old’ and opia pertaining to ‘the eyes’. It is caused by the gradual loss of elasticity of the lens necessary to change its shape in order to focus. Presbyopia affects everyone and while there is no cure, it can be corrected with glasses.

Cataracts

A cataract is a clouding of the normally clear lens of the eye caused by a buildup of protein. As they grow, cataracts eventually prevent a light image from reaching the retina resulting in diminished vision. Most cataracts are related to aging and affect more than half of individuals by the age of 80. Cataracts develop slowly over time and can affect one or both eyes. They may begin to develop in middle age, but in the early stages of cataract development you may not be aware that you have one. Symptoms of a cataract can included blurred vision, faded colors and diminished night vision. Diabetes, smoking, alcohol use and exposure to sunlight may put you at increased risk for developing a cataract. Cataracts can also develop as a result of an eye injury or after eye surgery or can be present at birth (congenital cataracts). Cataracts are diagnosed during a full eye examination by an ophthalmologist or optometrist. Vision with a cataract may be improved with eyeglasses and better lighting, but when they begin to interfere with the activities of daily life, surgery may be necessary. The procedure is usually performed on an outpatient basis by an ophthalmologist and most often consists of removal of the clouded lens and replacement with a clear, artificial one. One of my elderly patients told me that after her cataract surgery she was shocked when she looked in the mirror and saw how many wrinkles she had developed since her vision had become affected!

Glaucoma

Glaucoma is an increased pressure in the eye which can damage the optic nerve that transmits images to the brain. It is the second most common cause of blindness in the U.S. after cataracts. The anterior chamber of the eye behind the colored iris is filled with a fluid called the aqueous humor. New fluid is continually being formed and the excess is normally drained through channels in the angle between the iris and the cornea, keeping pressure in balance. Anything that obstructs these channels can cause the intraocular pressure to go up resulting in glaucoma.

There are four types of glaucoma:

(1) Open-angle or chronic glaucoma is the most common type and tends to run in families. There may be no symptoms until severe damage has already been done. Most patients can be successfully treated with eye drops.

(2) Angle-closure or acute glaucoma occurs when there is an abrupt closure of the channels which drain the aqueous humor. There may be sudden, severe pain in one eye, redness and decreased vision. This is a medical emergency and drops or other medication is used to decrease the pressure and prevent blindness. Occasionally an operation called an iridotomy is necessary.

(3) Congenital glaucoma is present at birth, is usually inherited and is generally treated with surgery.

(4) Secondary glaucoma is caused by medications, such as long term steroid use, trauma or other eye diseases. Treatment depends on the cause.

Glaucoma is diagnosed by an eye care professional, generally by testing the eye pressure. Everyone should have a complete eye examination by age 40 or sooner if you have a family history of glaucoma.

Macular Degeneration

Age-related macular degeneration (AMD) is a condition that affects older individuals, as its name implies, and is one of the most common causes of visual impairment and blindness in those over 50 years old. It results from damage to the center of the retina (macula) which causes loss of vision in the center of one’s field of vision. Because the area of the macula is important for providing detailed, sharp vision, patients with AMD have difficulty reading, watching television and recognizing faces. AMD does not cause complete blindness and most patients can compensate to some extent by taking advantage of their peripheral vision. There are two basic types of AMD, the more severe wet or exudative form which accounts for 10% of cases and the more common dry or nonexudative form. There is no treatment for the dry form which is caused by accumulation of cellular debris beneath the retina. The abnormal growth of blood vessels which characterizes the wet form can be treated with laser coagulation and medication to slow the growth of the blood vessels. Both types can cause retinal detachment. While there is no pain related to AMD, symptoms include blurred vision, missing areas of vision and distorted vision where straight lines appear wavy. Caucasians, those with a family history and smokers have an increased risk of developing AMD. Macular degeneration should be diagnosed and managed by an ophthalmologist.

Diabetic Retinopathy

Just as both type 1 and type 2 diabetes contribute to damage to the medium and large blood vessels of the heart and brain (macroangiopathy), they also cause damage to the small blood vessels and capillaries of the kidneys, eyes and nerves (microangiopathy). In the case of the eyes, diabetes affects the blood vessels of the retina, the light sensitive tissue lining the back inner surface of the eye. The damage develops slowly over time and patients may not notice it at first. Eventually, however, it will cause loss of vision and can lead to blindness. Diabetic retinopathy will be more severe in those who have had diabetes longer, or have a more severe case or have poorly controlled diabetes. Almost 80% of patients with diabetes for ten years or more will have manifestations of diabetic retinopathy. In addition to carefully controlling their diabetes under the supervision of a health care provider, it is imperative that all patients with diabetes be followed by an ophthalmologist, refrain from smoking and control blood pressure and cholesterol levels. These measures may help to slow the progression of diabetic retinopathy. An ophthalmologist can diagnose the early stage of diabetic retinopathy, known as the nonproliferative form, by identifying blocked or dilated blood vessels in the retina during an eye examination. At this stage no treatment may be necessary. An ophthalmologist will be able to identify progression to the more severe stage of diabetic retinopathy, known as the proliferative form, where new blood vessels begin to form (neovascularization) which can bleed and cause scarring on the retina. At this stage he may begin treatment with a procedure called laser photocoagulation to stop the blood vessels from leaking or to obliterate abnormal ones. With the increasing incidence of diabetes due to changes in lifestyle such as diet and activity levels, diabetic retinopathy is sure to remain a major cause of visual impairment throughout the world. Its economic and personal impact will be all the more significant because it affects patients in their middle years, the years which for most individuals are their most productive.

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Common Eye Infections

John T. Rowe, MD / August 17, 2012

Stye

A stye is an acute inflammation of the eyelid caused by an infected eyelash hair follicle or blockage of one of the oil glands that lubricate the eyeball. The resulting collection of pus or abscess is usually caused by the Staphylococcus bacteria. The lesion can occur on either the upper or lower eye lid and on either the inner or outer surface of the lid. The medical term for a stye is hordeolum. Styes occur more often in children than adults and occasionally become recurrent. Symptoms include pain, swelling, redness and drainage of pus. Styes usually occur spontaneously, but irritation, rubbing, eye makeup, contact lenses and poor hygiene may increase the risk of developing a stye. Treatment is usually with hot compresses and the nodule generally ruptures on its own within two to four days. A stye should not be pressed or squeezed in an attempt make it drain. Occasionally a stye on the inner lid will require drainage by a physician. A chalazion is another lump that can form on the eyelid, usually farther from the edge, and it is also caused by blockage of an oil producing gland in the eyelid. It does not cause pain, is not infected and is often larger than a stye. If a stye doesn’t drain and heal completely it can turn into a chalazion. Chalazia often resolve within a few months without treatment, but may require medical intervention.

Blepharitis

Blepharitis is another condition affecting the eyelids and is characterized by inflammation at the base of the eyelashes. It affects a larger area than the single lesion of the stye and is caused by bacterial or skin conditions that affect the eyelids, producing dandruff like scales. The most common causes of blepharitis are overgrowth of the normal skin bacteria, blockage of oil glands in the eyelids or less often allergies. Blepharitis can affect all age groups and is not contagious. It tends to be a chronic condition causing irritation and itching and can be difficult to treat. Treatment often includes lubricating oils, antidandruff shampoo, good hygiene and softening of crusts with the application of warm compresses. Blepharitis is one of the skin conditions that may increase the likelihood of developing styes and chalazia.

Conjunctivitis or Pink Eye

Conjunctivitis is usually caused by a bacterial or viral infection affecting the outer layer of the eye. It is often called pink eye because of the pink appearance of the sclera or white part of the eye. It most commonly affects children and is extremely contagious. Pink eye is spread by direct contact or by sharing an article used by an infected individual such as makeup or even a towel. Good hygiene and hand washing are important measures for preventing pink eye. In addition to redness, symptoms can include tearing, discharge, itching and irritation. Because of their similar signs and symptoms, allergies affecting the eyes can sometimes be difficult to distinguish from infectious pink eye. Depending on the cause, pink eye usually lasts one to two weeks and runs its course with only symptomatic treatment. However, some types of conjunctivitis require antibiotics.

Several types of conjunctivitis deserve separate mention because they require special treatment to prevent complications. Newborns can acquire conjunctival infections caused by either the gonococcus or chlamydia bacteria as they pass through the birth canal if the mother has an active case of one of these sexually transmitted diseases. All newborns receive treatment with the instillation of a prophylactic agent into the eyes to prevent gonococcal ophthalmia and are screened for conjunctivitis caused by chlamydia. Viral keratitis and conjunctivitis can be caused by both the herpes simplex virus (Type I which also causes cold sores) and the varicella-zoster virus (shingles). It is important to have an ophthalmologist diagnose and treat these infections to prevent complications which can include diminished vision.

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Common Eye Injuries

John T. Rowe, MD / July 22, 2012

Built in Protection

Because of its importance and vulnerability, the eye has evolved a number of effective defense mechanisms to shield it from injury. Its recessed position within the protective orbital bones is the first line of defense for the human eye. Much more than just fashionable accoutrements, the eyelashes and even the eyebrows serve as an early warning system, telling us to blink or move away when something gets close to our eyes. And tears do much more than just express our emotions. They keep the eyes moist and lubricated and they flush foreign matter away from the surface of our eyes. Despite these important defenses, the eyes are still vulnerable to injury. Let’s take a look at some of the more common eye injuries, keeping in mind that while this list is by no means all-inclusive, it will give you a basis for recognizing and managing some of the more common injuries.

Corneal Abrasions

One of the most common injuries occurs when a foreign body or fluid gets onto the surface of the eye, which can cause redness, irritation and tearing. A common scenario would be when a speck of sand blows into your eye and the resulting irritation causes you to rub it. A foreign body such as this speck of sand or anything moving across the surface of the eye can cause a small scratch called a corneal abrasion. Occasionally a foreign body can become embedded in the eye. In either case, your physician can make the diagnosis using fluorescein dye drops and a blue light to detect damage to the cornea. If left untreated, a large abrasion or an embedded foreign body can cause infection or, in the case of a metallic foreign body, deposition of a rust ring. Along with the lining of the mouth and tongue, the epithelial layer of skin on the cornea is one of the fastest areas of the body to heal and a simple corneal abrasion should resolve in 24 to 36 hours.

Chemical Burns

If a harmful chemical, either fluid or less often powder, gets into the eye it can cause anything from mild irritation to a serious chemical burn. The severity of the burn depends on the composition of the chemical and length of time it is in contact with the eye. The most dangerous substances are strong acids or alkali. This is one of the most common eye injuries and severe cases require immediate treatment and evaluation by an ophthalmologist. The pain may make it difficult for the patient to open the injured eye, but the eye should be opened and flushed with clean water or saline even before medical assistance is available. Proper eye protection and eye wash stations in the workplace or school laboratory are essential for preventing and treating this potentially serious injury.

Black Eye

A ‘black eye’ is a bruise caused by bleeding into the facial tissue around the eye. It can be due to an injury to the face or periorbital region and while it is usually benign, it can indicate a more serious injury such as a skull fracture. Treatment consists of applying an ice pack to the area without putting pressure on the eyeball itself. Evaluation by an ophthalmologist is advisable, especially if vision is affected or if there is damage to the eyeball. A simple black eye should resolve in 3 to 5 days. It is important to note that two black eyes, known as ‘raccoon eyes’ can indicate a more serious head injury such as a skull fracture.

Subconjuntival Hemorrhage

A subconjuntival hemorrhage occurs when there has been leakage from a blood vessel into the area between the sclera (white of the eye) and the conjunctiva covering it. While it is usually caused by mild trauma to the eye, a subconjunctival hemorrhage can occur after straining or coughing and occasionally they occur spontaneously. A subconjuntival hemorrhage usually looks worse than it is and generally does not cause pain. In most cases no treatment is required and the area of redness clears over a period of a week or so.

Orbital Fracture

The results of blunt trauma to the eye can include two serious eye injuries, orbital fracture and hyphema. The orbit is the boney casing in the front of the skull that contains the eye. It is composed of seven bones and any of these can sustain a fracture usually due to blunt force from something larger than the eye itself, such as a ball or fist. An orbital blowout fracture occurs when the increased pressure in the orbit from the blow causes the weakest point at the floor of the orbit to ‘blow out’. Signs and symptoms can include black eye, swelling, difficulty moving the eye and abnormal position of the eye. Prompt medical attention and evaluation by an ophthalmologist is essential and surgery is often necessary to correct the injury.

Hyphema

A hyphema is caused by bleeding into the anterior chamber of the eye, the front part of the eye between the cornea and the iris. It is usually caused by blunt trauma to the eye and is manifested by pain, sensitivity to light and blurred vision. Evaluation by an ophthalmologist is essential to confirm the diagnosis and determine the course of treatment. In mild cases hyphema may resolve spontaneously with bed rest, elevation of the head of the bed and a protective eye shield. Serious cases can cause an elevation of pressure within the eye which could lead to glaucoma and require surgery.

Penetrating Eye Injuries and Lacerations

A penetrating eye injury is where the outer membranes of the eye are disrupted and requires immediate evaluation and treatment. It can be one of the most serious eye injuries and can lead to significant loss of vision or loss of the eye without proper treatment. Some common objects responsible for penetration injuries of the eyes include rocks, lumber, fishing weights, baseballs, sticks, knives, scissors and screwdrivers. A laceration or cut in the tissue surrounding the eye requires evaluation to rule out a more severe accompanying eye injury. It may also require the skilled hands of an ophthalmologist or plastic surgeon, particularly when the eyelid is involved, to insure a good cosmetic result. You should always check with your health care provider if you have any questions about a possible injury to your eyes. In our next article we’ll look at some common eye infections.

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The Amazing Human Eye

John T. Rowe, MD / June 13, 2012

The Eyes Have It

The eye is the lamp of the body, the window to the soul, and a mirror of the heart, according to the various philosophers, poets and evangelists. Just what is this amazing organ, which many describe as an incredible gift of nature, that it can be all these things? Attesting to its intricacy and importance, the human eye is the smallest single organ to have an entire medical specialty (ophthalmology) and an entire ancillary medical specialty (optometry) devoted to preventing and treating its problems and maximizing its usefulness.

As perhaps the most important and most cherished purveyor of the five senses, our eyes play a unique role in how we navigate through life in a world overflowing with visual stimuli. Let’s take a closer look at this amazing organ, reviewing some of the basics of how the eye works and what we can do to care for them. In future articles in this series we will review some of the more common eye disorders.

How the Eye Works

Just one example illustrating the incredible nature of the eye is the way in which it evolved in a similar manner over time in animal lines as divergent as cephalopods (such as squid), vertebrates (such as mammals, reptiles, birds and fish) and cnidaria (such as jellyfish). Some would call this an accidental phenomenon known as convergent evolution. Others see this as a purposeful miracle created by a greater power. Regardless, in each of these different types of living organisms the end result of the development of the eye has been similar, basically resulting in a structure that operates like a camera.

The Amazing Human Eye

Light rays reflecting an image first pass through the cornea, the transparent structure that covers the front part of the eye. The light rays are then focused and directed through the pupil, the dark, circular opening in the center of the colored iris that operates in a similar fashion to the aperture on a camera. The rays then pass through the lens which helps to focus them on the retina lining the back inner surface of the eye. The retina is analogous to the film of a camera but contains photoreceptor nerve cells that convert the light into electrical impulses which then travel by way of the optic nerve to the brain where the image is perceived. Of course, there is no way to adequately describe the workings of such an incredible organ in just one paragraph, but this will give you the basics to build on as you continue to explore the wonders of the human eye on your own.

Basic Eye Care

There is much that you can and should do to ensure that your eyes stay healthy for a lifetime. Basic eye care includes proper nutrition and exercise, wearing protective eyewear, knowing your family health history and getting regular eye exams at the appropriate intervals. A diet rich in fruits, vegetables (especially green, leafy vegetables) and fish has been shown to be beneficial to the eyes. Maintaining your ideal weight and not smoking is also important to prevent diseases that affect the eyes, such as diabetes and macular degeneration. Wearing the appropriate protective eyewear both at home and in the workplace is essential, whether it be while engaging in sports and other recreational activities or operating equipment like a weed eater while gardening at home. Wearing sunglasses will protect your eyes from the harmful effects of UV radiation from the sun.

‘Near work’ such as looking at a computer screen can strain your eyes, so resting the eyes at intervals during such activities is important. For children, unnecessary near work such as playing computer games should be limited and substituted instead with outdoor activity. Studies have shown that daily outdoor activity may prevent the development or progression of myopia, a refractive error making distant objects appear blurred. Finally, regular eye examinations throughout life (especially important during childhood and the golden years) will help identify eye problems early so that corrective measures can be taken. In our next article we will take a look at some of the common eye disorders.

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Number of Newborns with Drug Withdrawal Triples

John T. Rowe, MD / May 2, 2012

An article appearing in the Journal of the American Medical Association on April 30, 2012 by Dr. Stephen W. Patrick et al reports that between 2000 and 2009 the number of newborns in the United States diagnosed with neonatal abstinence syndrome nearly tripled. Neonatal abstinence syndrome or NAS is a drug withdrawal syndrome in newborns primarily caused by maternal opiate use. This study also found that maternal opiate use increased nearly 5-fold, a trend that mirrors the general increase in opiate use, both legal and illegal, across the country.

Infants born with neonatal abstinence syndrome exhibit symptoms such as irritability, seizures, respiratory distress and feeding difficulties. Other adverse effects for infants of mothers who used opiates during pregnancy include low birth weight and increased mortality. Infants with NAS may need prolonged care, often in an intensive care unit and some require treatment with methadone to wean them from the effects of the opiates used by their mothers during pregnancy. The increased cost to an already overburdened health care system is shouldered by Medicaid programs in nearly 80% of the cases.

To learn more about neonatal abstinence syndrome see the original article by Dr. Stephen W. Patrick et al titled Neonatal Abstinence Syndrome and Associated Healthcare Expenditures.

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Gluten

John T. Rowe, MD / April 2, 2012

What’s All the Fuss about Gluten?

It has become quite fashionable these days for otherwise healthy individuals to go on a gluten-free diet. You may have even contemplated whether you should try eliminating gluten from your diet. There are many, however, who wonder if this is just another in the long list of fad diets that come in and out of vogue. Gluten is a protein found in wheat, rye and barley that can cause a serious condition called celiac sprue in a specific group of individuals and may lead to less severe symptoms in others who are thought to have gluten sensitivity. Most of us, on the other hand, have no problem when gluten is included in our diet. As we will see, following a gluten-free diet is difficult and can lead to certain dietary deficiencies. Once you are armed with the facts you should be able to make an informed decision about gluten in your diet.

Celiac Sprue

Celiac sprue or gluten-sensitive enteropathy affects 1 in every 150 to 250 individuals in the United States and Europe and the incidence seems to be increasing. It occurs when a genetically predisposed person ingests the protein gluten from wheat, rye or barley and an immune response directed against the gluten proteins causes inflammation in the mucosal lining of the small intestine. Signs and symptoms include diarrhea, bloating, flatulence, weight loss, fatigue, abdominal pain and skin problems. The resulting malabsorption can lead to malnutrition, iron deficiency anemia and vitamin D and vitamin K deficiency. Diagnosis can be made through biopsy of the small intestine and serologic testing. Approximately 20% of new diagnoses of celiac sprue are made in adults over the age of 60 years. Treatment consists of a lifetime adherence to a gluten-free diet and most patients experience an improvement within a few weeks of beginning the diet.

Gluten Sensitivity

Medical experts have begun to accept the idea that some individuals may have a reaction to gluten even though they test negative for celiac sprue. This condition is referred to as gluten sensitivity. These patients may experience some of the same signs and symptoms as those with celiac disease and they improve with a gluten-free diet. Patients who suspect that they may have a reaction to gluten should be evaluated by their physician and should be tested for celiac disease first before embarking on a gluten-free diet.

Are There Any Disadvantages to Following a Gluten-Free Diet?

Besides being difficult to follow, a gluten-free diet may cause a deficiency of minerals such as iron and calcium, as well as certain vitamins like B12 and Vitamin D. A gluten-free diet can also mean that you are getting less dietary fiber. While this restrictive diet has been touted for everything from migraines to autism, there is currently no evidence that a gluten-free diet helps these or other conditions such as Down Syndrome or ADHD. Following a gluten-free diet does not necessarily promote weight loss either. In fact, foods labeled as gluten-free in the grocery store may actually be higher in carbohydrates, fats and sodium.

The Bottom Line

Those who have undergone appropriate testing which confirms that they have celiac disease must adhere to a gluten-free diet for life and should experience an immediate improvement after beginning the diet. Others who have some of the symptoms of celiac disease but negative test results may have gluten sensitivity and may benefit from eliminating gluten from their diet. While the jury may still be out on whether a gluten- free diet is beneficial for otherwise healthy individuals, it is important to be aware that following this diet can lead to vitamin and mineral deficiencies. As always, it is important to consult your health care provider or a dietitian if you have questions about gluten and whether a gluten-free diet may benefit you.

Guidelines for Following a Gluten-Free Diet

Because many of us are gluttons for gluten, following a gluten-free diet can be difficult. This is because so many of the tasty things we enjoy eating contain gluten. Cross contamination and food additives also make it difficult to insure that you are not ingesting gluten. Grocery stores now have many items labeled ‘gluten-free’, which may mean that they contain a harmless level of gluten, but are not necessarily completely devoid of gluten. For all these reasons, it would be a good idea to consult a dietitian before embarking on a gluten-free diet.

Gluten-Free Diet Guidelines

Foods That Are Allowed

corn

flax

rice

soy

potato

beans, seeds, nuts

eggs

most dairy products

fruit and vegetables

meat, fish and poultry

Foods That Are Not Allowed

barley

rye

wheat

Foods to Avoid Unless Labeled Gluten-Free

pasta

gravy

French fries

croutons

crackers

cereal

candy

cakes and pies

bread

beer

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