13 posts categorized "In the Journals"

February 18, 2011

Eye Drop to Prevent Cataracts?

For many, the formation of cataracts is a natural part of the aging process, causing the eye's natural lens to cloud and distort vision. The lens is held inside a capsule, and is made of mostly protein fibers and water arranged precisely so as to permit light to pass through without interference. Over time, these fibers begin to break down and cluster together, clouding the lens. As more fibers break down, the clouding becomes denser and covers a greater area of the lens. Cataract surgery becomes necessary to restore clear vision.

In China, there is a non-prescription eye drop that has been used for over 60 years to prevent and treat cataracts.  The active ingredient of this drop is caled pirenoxine (PRX).  There has been no scientific basis for the effectiveness of PRX, until now...

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In last months issue of Inorganic Chemistry is an article titled Ditopic Complexation of Selenite Anions or Calcium Cations by Pirenoxine: An Implication for Anti-Cataractogenesis.  In the study, Tzu-Hua Wu and colleagues tested PRX on cloudy solutions that mimic the chemical composition of cataracts. The solutions contained crystallin -- a common lens protein -- combined with either calcium or selenite, two minerals whose increased levels appear to play key roles in the development of cataracts. Presence of PRX reduced the cloudiness of the lens solution containing calcium by 38 percent and reduced the cloudiness of the selenite solution by 11 percent.

"These results may provide a rationale for using PRX as an anti-cataract agent and warrant further biological studies," the article notes.  Who knows, there may be a time in the not to distant future when we will be prescribing these drops to ward off cataract surgery!

December 15, 2010

Pupil Size Not A Factor in LASIK Outcomes

There is an interesting article presented for publication in Ophthalmology titled:  Effect of Preoperative Pupil Size on Quality of Vision after Wavefront-Guided LASIK by Annie Chan MD and Edward E. Manche MD out of Stanford University.  This paper studies what I have noticed for a long time:  pre operative pupil size does not effect quality of vision in wavefront guided LASIK

Although large pupil size is viewed by some ophthalmologists as a relative contraindication to undergoing LASIK, preoperative pupil size does not affect quality of vision after wavefront-guided LASIK.  There is no doubt that with first generation lasers, pupil size was an important factor in determining night vision issues,.  However, I soon noticed that this was not the case when I upgraded to the Allegretto laser over 5 years ago.  This study supports my observations.

The study evaluated the effect of pupil size on quality of vision after wavefront-guided LASIK in a  study of 51 patients undergoing the procedure for mild to moderate myopia or astigmatism.  Pupil size was divided into 3 groups:

  • 31 small pupils (up to 5.5 mm)
  • 36 medium pupils (5.4-6.4 mm)
  • 32 large pupils (at least 6.5 mm)

Night time glare, haze, and halo scores were increased for all pupil sizes in the first month, but improved over the folowing months. There was no significant differences among the 3 groups.   Visual clarity at night and day improved from baseline at all visits, and there was no association between pupil size and these measurements.

The authors conclude:

A number of previous studies found a strong correlation between the level of attempted correction and visual symptoms, particularly glare, after refractive surgery.  It is possible that the use of wavefront-guided ablations may play a role in reducing visual symptoms after refractive surgery, especially in eyes with higher levels of myopia and astigmatism.

Further comparative studies are needed to validate this hypothesis.

This paper supports what I have been telling my patients for a long time:  although it has been reported in the past that night vision issues may be related to pupil size, I do not see it with the Allegretto laser, in fact, I more commonly see an improvement in night vision as compared to glasses or contact lenses.

November 15, 2010

Cataract Prevention? Vitamins are Not The Answer!

According to WebMD

Vitamin C is one of the safest and most effective nutrients, experts say. It may not be the cure for the common cold (though it's thought to help prevent more serious complications). But the benefits of vitamin C may include protection against immune system deficiencies, cardiovascular disease, prenatal health problems, eye disease, and even skin wrinkling. 

Vitamin E is key for strong immunity and healthy skin and eyes. In recent years, vitamin E supplements have become popular as antioxidants. These are substances that protect cells from damage.  Many people use vitamin E supplements in the hopes that the vitamin's antioxidant properties will prevent or treat disease. Early lab studies of vitamin E supplements were promising. But studies of vitamin E in people have been disappointing.

There was an interesting article in this months issue of Archives of Ophthalmology titled: Age-Related Cataract in a Randomized Trial of Vitamins E and C in Men.

This article assesed whether supplementation with alternate-day vitamin E or daily vitamin C affects the incidence of age-related cataract in a large cohort of men. 11,545 apparently healthy US male physicians 50 or older without a diagnosis of cataract at baseline were randomly assigned to receive 400 IU of vitamin E or placebo on alternate days and 500 mg of vitamin C or placebo daily. After 8 years of treatment and follow-up, there were 579 cataracts in the vitamin E–treated group and 595 in the vitamin placebo group. For vitamin C, there were 593 cataracts in the treated group and 581 in the placebo group.

The study concluded that long-term alternate-day use of 400 IU of vitamin E and daily use of 500 mg of vitamin C had no notable beneficial or harmful effect on the risk of cataract.

There are a few things you can to to slow down cataract formation:

  • Wear sunglasses
  • Quit smoking
  • Maintain a healthy weight

And, if you do develop visually significant cataracts, not to worry.  Cataract surgery is the most common procedure performed in the US with 1.5 million performed annually.  Combined with the implantation of an IOL (intraoccular lens), the results are excellent..

September 27, 2010

1 to 2 Drinks a Day Lowers Cataract Incidence, I'll Drink to That!

In last month's American Journal of Ophthalmology was an interesting article, Alcohol Consumption and the Long-Term Incidence of Cataract and Cataract Surgery: The Blue Mountains Eye Study. This study evaluated if there was any correlation between alcohol consumption and cataract formation in over 3,500 people over the age of 49 years.

The results were very interesting:

  • After adjusting for age, gender, smoking, diabetes, myopia, socioeconomic status, and steroid use, total alcohol consumption of over 2 standard drinks per day was associated with a significantly increased likelihood of cataract surgery.
  • Abstinence from alcohol was also associated with increased likelihood of cataract surgery when compared to a total alcohol consumption of 1 to 2 standard drinks per day.

The conclusion:

A U-shaped association of alcohol consumption with the long-term risk of cataract surgery was found in this older cohort: moderate consumption was associated with 50% lower cataract surgery incidence, compared either to abstinence or heavy alcohol consumption.

This study seems to support the belief that moderate consumption of alcohol is beneficial to our health.  If you are looking for a good source for a wine deal, check out Cinderella Wine.  They offer a daily that expires at midnight.  What a great name! 

Just remember, stop after that second glass!!

September 16, 2010

Parents Beware: Laser Pointers Not Toys!!

There was a very intersting Letter to the Editor in last weeks New England Journal of Medicine last week, Retinal Injuries from a Handheld Laser Pointer.  The authors report a case of a 15 year old boy who bought a laser pointer on the internet to use as a toy. 

The boy’s life changed when he was playing with his laser pointer in front of a mirror to create a “laser
show,” during which the laser beam hit his eyes several times. He noticed immediate blurred vision in both of his eyes. Hoping that the visual loss would be transient and afraid of telling his parents, he waited 2 weeks before seeking an ophthalmic assessment, when he could no longer disguise his bad vision. His visual acuity was so poor in his left eye that he was only able to count fingers at a distance of 3 ft, and it was 20/50 in his right eye.

The clinical findings were consistent with severe bilateral retinal laser injury. After 4 months, the boy’s visual function remained impaired but improved to 20/32 in the right eye spontaneously and to 20/25 with a remaining scar just beside the center of the fovea in the left eye after one intravitreal injection of ranibizumab

This kid was very lucky, although he does have a visual deficit, he had an excellent response to treatment!  There are several take away points from this letter:

  1. Never shine a laser pointer at anyone. Laser pointers are designed to illustrate inanimate objects.
  2. Do not allow minors to use a pointer unsupervised. Laser pointers are not toys.
  3. Do not point a laser pointer at mirror-like surfaces. A reflected beam can act like a direct beam on the eye.

June 14, 2010

Traumatic Dislocation of LASIK Flaps 4 and 9 Years After Surgery

I have an article published in this month's Journal of Refractive Surgery titled: Traumatic Dislocation of LASIK Flaps 4 and 9 Years After Surgery.  With the help of UMDNJ ophthalmology resident, H. Jane Kim, we published two cases of traumatic flap dislocation following LASIK.  One of the cases occurred 9 years following LASIK, making it the longest reported case medical literature.  In this case the flap dislocated when my patient was struck in his eye with a dog's paw.  After treatment both of my patients vision improved to 20/20.

This article brings up an important point, there is a potential to dislocate the LASIK flap if one is hit at the right angle, years after LASIK surgery.  This is one of the reasons I advocate treating those patients who are involved in activities (boxers, special forces, etc) that may preclude them to get hit in the eye with surface treatments such as LASEK.  This procedure creates no flap, and thus minimizes future risk.

Flawed Conclusions: Physician Ownership Linked to Higher Surgery Volume


There has been a lot of buzz on the web this past week concerning an article in this month's Health Affairs titled: Physician-Ownership Of Ambulatory Surgery Centers Linked To Higher Volume Of Surgeries.  In this article, John M. Hollingsworth, M.D., of the University of Michigan in Ann Arbor, and colleagues used  Ambulatory Surgery Databases to analyze data from Florida from 2003 to 2005. They looked at all patients in Florida who underwent one of five common outpatient procedures including  cataract extraction. They compared the number of surgeries performed among ASC owners before and after they acquired ASC ownership with that of physicians who were non-owners. They found that owners performed  twice as many procedures as non-owners.  Assuming that these are the facts of the study, you can't argue with numbers; what I have a problem with is the author's conclusion:

"To the extent that owners are motivated by profit, one potential explanation for our findings is that these physicians may be lowering their thresholds for treating patients with these common outpatient procedures."

I find this conclusion offensive.  Lowering treatment parameters to generate profits?  Cataracts cause a decrease in one's vision, what patient is going to submit to eye surgery without the symptoms that warrant this surgery?  I have been a part-owner in River Drive Surgery Center for the past 8 years.  During this time, my cataract volume has certainly increased.  It is NOT because  profits have lowered by treatment parameters!  Here are some of the reasons that I can think of of the top of my head (I find it amazing the that author's of this paper couldn't come up with any of these):

  • Patient friendliness.  Patients find the ASC setting much less daunting than the hospital setting.  They are not shuffled from department to department, they are treated as individuals in a very caring matter.
  • Efficiencies. ASC's are much more efficient than hospitals.  When I did my cataract surgery in a hospital, I found myself sitting around for the room to be ready.  It was difficult to do more than 1 procedure per hour.  In my ASC, there is no waiting for a room, and no down time.  I am now able to perform 6 cataracts an hour, without rushing.
  • Costs.  ASC's are able to deliver care that is far superior than hospitals at a fraction of the cost.  This saves insurance companies as well as patients money.
  • Equipment.  By owning an ASC, surgeon-owners are now able to continually upgrade equipment.  At River Drive, we pride ourselves on always having the most current, cutting edge equipment.  This allows us to provide superior care to our patients!
  • Patient Experience.  We strive ourselves into providing a superior patient experience and outcome.  We generally succeed, and because we do, patients are apt to refer their friends and family to us for their surgery.  Success breeds success!
In conclusion, I agree with Dr. Hollingsworth, owners of ASC's do more cataract surgery!  However, this is NOT because we have lowered our operating standards.  It IS because we strive to do a better job.  Obviously, we are succeeding!

March 23, 2010

Photo Bleaching of Cataracts in Our Future?


I read an interesting article today in the New York Times, by Henry Fountain titled: Laser Treatment May Work for Cataracts.  The article describes some research out of Denmark, published on line in Plosone.

A cataract is an aging process whereby the eye's natural lens becomes more dense and opacified.  The main treatment for cataracts is surgery, removal of the lens with its replacement with an IOL.  As a worldwide treatment, this can be expensive, requiring a trained surgeon and an OR.  The authors of this paper are attempting to reverse the lens' aging process with the use of a laser to bleach the lens. 

The conclude:

femtosecond photolysis has the potential clinical value of replacing invasive cataract surgery by a non-invasive treatment modality that can be placed in mobile units, thus breaking down many of the barriers impeding access to treatment in remote and poor regions of the world.

This is certainly an interesting and novel approach towards addressing the world's leading cause of reversible blindness!

March 15, 2010

Anti-Depressants Linked to Cataracts, Now That's Depressing!


from  http://newzar.wordpress.com/2009/01/

A recent study, soon to be published in Ophthalmology, found that taking certain anti-depressants increased one's risk of developing cataracts.

The study was based on a database of more than 200,000 Quebec residents aged 65 and older.  The University of British Columbia (Vancouver) study showed a relationship between a diagnosis of cataracts or cataract surgery and the use of a class of anti-depressants called selective serotonin reuptake inhibitors (SSRIs).  Patients taking SSRIs were 15% more likely overall to be diagnosed with cataracts or to have cataract surgery.

The study also showed a relationship between cataracts and specific SSRI Class drugs.   Taking fluvoxamine (Luvox) led to a 51% higher chance of having cataract surgery, and venlafaxine (Effexor) carried a 34% higher risk. No connection could be made between fluoxetine (Prozac), citalopram (Celexa), and sertraline (Zoloft) and having cataract surgery.

March 04, 2010

Post Menopausal Women Beware: Hormone Replacement + Alcohol = Cataracts!?


Photo courtesy of http://www.theage.com.au/news/technology/quarks-gluons-and-corroborating-emc2/2008/11/21/1226770694126.html

There is an interesting article in this month's Ophthalmology titled Hormone Replacement Therapy in Relation to Risk of Cataract Extraction: A Prospective Study of Women.

This study included 30,861 women aged 49 to 83 years who completed a questionnaire about hormone status, use of hormone replacement therapy (HRT) and lifestyle. Of these, 4,324 women underwent cataract surgery during the 98-month follow-up interval.

Results showed:

  • Women who had ever used HRT had a 14% higher risk of cataract than women who had never used therapy.
  • Current HRT users had an 18% higher risk of cataract than women who never used HRT.
  • In women who consumed alcohol, current HRT users had a 29% higher risk of cataract extraction than those who did not use therapy.
  • Current HRT users who consumed more than one alcoholic beverage daily had a 42% higher risk of cataract.

The study concluded that postmenopausal women using HRT for a long period of time may be at an increased risk for cataract extraction, especially those drinking >1 alcoholic drink daily.

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It certainly makes sense for women who are or have beenon HRT to limit their alcohol intake if they wish to reduce their risk of cataract development.