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John C Hagan III, MD, FACS, FAAO  
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Kansas City, MO

Specialties: Ophthalmology

Interests: Eye-Medical Blog

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THE RISKS OF MARIJUANA ARE MANY AND SEVERE

Dec 04, 2013 - 35 comments

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Posted on Tue, Dec. 03, 2013

By Ravikumar Chockalingam MD and Dragan Svrakic MD
Special to The Kansas City Star

Imagine the public outrage if a toxic drug was approved without any regulation for “recreational” use in adults and children that suppresses the immune system, causes schizophrenia, mental illness, brain and lung disease including cancer and death. Also, many long-term and frequent users of this toxic drug have lowered IQs, impaired memory, poor judgment and diminished driving ability.

Finally, suppose this toxic drug is sold “for medical use” to treat diseases for which safer medications are available and at the same time puts them at greater risk of addiction to other substances. Public outrage would be unprecedented; the FDA would be severely and rightly criticized for not subjecting this toxic drug to study. Trial lawyers would be everywhere soliciting lawsuits against the manufacturer.

The toxic drug is marijuana (cannabis) and this nightmare health scenario has occurred in other states. It might occur in Missouri or Kansas if ill-informed and misleading groups like John Payne’s Show-Me Cannabis (As I See It, 10/20/2013) have their way. There is already a considerable amount of medical research showing marijuana to be harmful that is never mentioned by advocates of legal marijuana.

Sadly, this research is largely ignored or underreported by the media. When properly viewed, as a drug subject to FDA study, marijuana would be declared not safe, not effective and not approved based on studies already published in medical journals.

As physicians we attest that the dangers of “medical marijuana” far exceed any therapeutic usefulness, particularly in the context of safer and more evidence-based alternate treatment. Legal cannabis is a bad drug trip the public should avoid.

Like deadly asbestos fibers, the long-term adverse medical consequences may take decades to appear.

The National Survey on Drug Use and Health reported that 55 percent of marijuana users are between 12 and 18 years old. They frequently go on to use more dangerous drugs. Marijuana users have higher “driving while intoxicated” convictions than alcohol users. In 2004, during the five years following legalization of cannabis in California, marijuana-related fatal motor vehicle accidents increased. Marijuana use on the job is common and more problematic than alcohol use.

Cannabis users have slower reaction times, impaired thinking, reduced levels of alertness and poor memory compared to non-users. This leads to higher on the job accident rates and defective or dangerous workmanship.

With 2.5 million new users of marijuana in 2012 age 12 and older (6,800 new users per day) legalizing marijuana will dramatically increase these numbers. Marijuana use in elementary, middle and high school will become common. Parents and educators should be dismayed that long-term marijuana use has been associated with an irreversible eight-point drop in IQ. No wonder cannabis has long been known as “dope.”

Marijuana is a noxious drug with proven medical side effects that trump any reason to legalize its use. Our understanding of this drug and its consequences negates all reasoning to make this readily accessible to public.

Ravikumar Chockalingam of St. Louis is a psychiatry resident at Barnes Jewish Hospital-Washington University School of Medicine. Dragan Svrakic of St. Louis is an associate professor of psychiatry at the Washington University School of Medicine and the St. Louis Veterans Affairs Medical Center.

This appeared in the "As I See It" Editorial, Kansas City Star  December 4, 2013

Eye Whitening Surgery; Iris Color Change Surgery; "bling" On Eye NOT RECOMMENDED

Oct 31, 2013 - 7 comments
Tags:

Surgical Whitening procedures

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Eyeball "bling"

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Cosmetic iris color change



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There are some very dangerous to moderately complication prone cosmetic procedures that are advertised on the internet. Articles are have been published in major Ophthalmology journals world-wide reporting complications anywhere from failing to make the eye whiter, to surgery necessary to remove "bling" to loss of the eye.

This is not cosmetic eye surgery to give the eyelids a more youthful appearance (blepharoplasty) or a rounder shape. Let us look at these other cosmetic eye operations that are causing problems starting with the most serious:

COSMETIC EYE COLOR (IRIS) CHANGE: First let's say what this isn't. We are not talking about surgery to rebuild a traumatized iris or an eye born without an iris (aniridia). This is legitimate surgery to correct often completely disabling light sensitivity and glare. It is done by skilled surgeons using prosthetic iris implants that have been clinically tested and approved by appropriate national agencies.   Nor is this using a laser to alter iris color although I would never recommend this surgery to a patient of mine. Nor are we talking about contact lens to alter the appearance of the eye iris color when worn if the contacts are fit by a skilled ophthalmologist or optometrist and worn by an informed and meticulous patient.  

So what are we talking about? NEVER is it worth considering having the eye have major surgery inside the eye in which an incision is placed in the cornea and a colored disk placed within the eye. This type of surgery has caused infection, bleeding, cornea clouding, chronic inflammation, severe pain, permanent loss of vision and blinded eyes. Many of these have been done in Panama. Other cosmetic iris intraocular implants allegedly are being done in Mexico and Turkey.  

COSMETIC PERMANENTLY PLACING OF TRINKETS ("BLING") ON THE SURFACE OF THE EYE.  These are not like body piercing, dental grill work or tattoos.  Often shaped like shamrocks, hearts, musical notes, etc. They have to be implanted surgically under the outer layer of the eye (conjunctiva) and over the white eye wall (sclera). Problems have included infection, inflammation, scar formation, chronically red and watery eyes. Removal surgery is often necessary and they eye may remain red and irritated looking and permanently watery and inflamed.

COSMETIC EYE WHITENING: This does not refer to removal of sun damaged tissue that is growing over the cornea called pterygia (singular pterygium). It does refer to surgery to remove pinguecula, thick tenon fascia or fat from the eye surface just to improve cosmetic appearance. Technically this is called "regional conjunctivectomy with or without post operative injection of mitomycin and/or bevacizumab".  A recent report (2013) in the American Journal of Ophthalmology of 557 people having this surgery found 70% post operative complications of which 34% were severe. 40% of the people having this surgery were dissatisfied or very dissatisfied. Dry eyes were common.
This type of surgery is reported to cost $3,500 to $5,500 USD and is not covered by insurance.

SUMMARY: At this writing (10/31/13) cosmetic iris implants surgically placed within the eye are NOT RECOMMENDED by almost all ophthalmologist, Eye MDs. Most all ophthalmologists would NOT RECOMMEND cosmetic eye whitening or cosmetic trinkets ("bling") placed surgically under the surface of the eye (conjunctiva). Assuming these risks to vision, eye comfort and appearance and incurring brutal out of pocket expenses in the hopes of making one slightly or questionably more attractive is not a rational or logical course of action.

John C. Hagan III, MD, FACS, FAAO
Ophthalmologist

photo: an uninflamed and thus far complication free  heart shaped "eye jewelry" (bad idea): source michaelKooren/Reuters/RichmondEye
  

Face Down Recovery After Macular Hole Surgery May Be Unnecessary

Oct 09, 2013 - 0 comments
Tags:

Macular Hole Surgery

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FACE DOWN POSTION



From one of the most prestigious medical journals:

OPHTHALMOLOGY   V120 #10 Pages 1998-2003 October 2013

Objective

To demonstrate the efficacy of broad internal limiting membrane (ILM) peeling and 20% sulfur hexafluoride (SF6) endotamponade with no face-down positioning in the surgical repair of idiopathic macular holes (MHs).

Design

Retrospective study.

Participants

Sixty-eight idiopathic MH cases in 68 eyes of 65 patients.

Methods

All idiopathic MH surgeries by 1 surgeon between March 2009 and December 2012, performed using broad ILM peeling, 20% SF6, and no face-down positioning, were reviewed. No cases were excluded. Surgeon method included 23-gauge or 25-gauge pars plana vitrectomy with induction of posterior vitreous detachment (if necessary). Indocyanine green dye (0.08 mg/ml in D5W) was injected slowly, allowed to stain for 60 seconds, and then removed. The ILM was broadly peeled to the vascular arcades (approximately 8000 μm in diameter), followed by 2 fluid–air exchanges, separated by 5 minutes, and an air–20% SF6 exchange. Patients maintained reading position for 3 to 5 days and were followed up at least for 1 month. Exact binomial distributions were used to establish 95% confidence intervals, and the 1-way analysis of variance was used to compare preoperative and postoperative intraocular pressures (IOPs).

Main Outcome Measures

Single-procedure MH closure rate, mean postoperative best-corrected visual acuity (BCVA), incidence of cataract, and IOP.

Results

Three patients (4.6%) had bilateral MH and 9 patients (13.8%) had recurrent MH (mean duration from previous surgery, 8.3±5.5 years; range, 1–16 years). Twenty-one MH (30.9%) were stage 2, 27 (39.7%) were stage 3, and 20 (29.4%) were stage 4. Five MH had a basal diameter of more than 1000 μm. Mean MH basal diameter was 609.6±226.2 μm. Mean preoperative BCVA was 0.68±0.29 logarithm of the minimum angle of resolution (logMAR) units (Snellen equivalent, 20/95), and mean most recent postoperative BCVA was 0.28±0.18 logMAR units (Snellen equivalent, 20/38). The single-procedure MH closure rate was 100% (95% confidence interval, 95%–100%), and no complications were observed.

Conclusions

Macular hole surgery with broad ILM peeling, 20% SF6 gas, and no face-down positioning is highly effective in the surgical treatment of idiopathic MH with efficacy comparable with methods that use longer-acting gas endotamponade, face-down positioning, or both. In our series, this method eliminated the morbidity associated with postoperative face-down positioning.

Financial Disclosure(s)

The author(s) have no proprietary or commercial interest in any materials discussed in this article.



Consider ALL the Options Before Your Cataract Surgery: Working Through What’s Best For You

Aug 10, 2013 - 30 comments
Tags:

Decisions before cataract surg



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Consider ALL the Options Before Your Cataract Surgery: Working Through What’s Best For You

John C. Hagan, MD, Fellow American Academy of Ophthalmology, Fellow American College of Surgeons.

Many decisions have to be made before having cataract surgery. The first is whether you need the surgery or not. Assuming you have made the decision to have surgery this is a discussion of the many options and choices you have.  THERE IS NO “BEST” TYPE OF PHACOEMULSIFICATION CATARACT SURGERY AND NO “BEST” INTRAOCULAR LENS. NO TARGETED POST SURGERY REFRACTIVE ERROR IS FOR EVERYONE. THESE DECISIONS WILL VARY FROM PERSON TO PERSON AND MUST BE INDIVIDUALIZED.  

We all have different visual needs.  Cataract surgery will be done earlier on a person needing perfect vision in all lighting circumstances, think airline pilots, truck drivers and heart surgeons. Surgery is done much later, if at all, on the very, very elderly, functioning combative or uncooperative dementia patients, those with terminal illnesses. In general cataract surgery is generally offered when a person is experiencing moderate or severe visual difficulties in activities they enjoy or need to do and the cataract is the sole or main cause.

Although the person is usually the one that makes the determination about how much of a problem his/her vision is in some cases surgery is strongly recommended by the ophthalmologist, optometrist or family.  Examples include inability to drive safely or legally; difficulty seeing the inside of the eye, major progressive physical or psychiatric disease, and if center of the cataract is getting “rock hard” (so called ‘brunescent or brown/black cataract) or could start to break up in the eye (so called ‘too ripe’).

Assuming cataract surgery is appropriate, the decisions that must be made include: which eye to operate on first, what type of IOL to insert, desired-targeted post-operative refractive error, how much glasses will need to be worn post operatively [NOTE: glasses are almost uniformly needed post operatively and are usually modern progressive bifocals]  SOME OF THE TIME a small % of people after cataract surgery can function without glasses or with inexpensive over the counter reading glasses.  Equally important is the choice of surgeon-ophthalmologist (Eye MD: a physician Doctor of Medicine or Doctor of Osteopathy that has been to medical school, medical-surgical residency and in many cases taken a special surgical fellowship.  Ophthalmologists provide a complete range of medical and surgical services.  Eye MDs must be distinguished from non-physician optometrists (OD) and opticians).

This discussion is not meant to be encyclopedic nor to give you “the answer.” As stated previous “the correct” answer will be different for different people. Informative is based on the most common questions posted on the American Academy of Ophthalmology MedHelp Eye Forums.

1. Where there is a difference of more than 1.50 diopters between the eyes post operatively glasses are often difficult or impossible to adjust to. The condition is called "aneisometrophia".  Part of the problem is due to the difference in image size each eye has with the glasses on; this is called “aneisokonia”.  Seek out Eye Forum posts on this problem by JodieJ. She had this problem post operatively and she clearly outlines her struggle and eventual success.
2. With modern cataract surgery not only do we try and make the person see better but we want the best possible vision without glasses and the two eyes to "work together" comfortably.  Tests are done preoperatively to help pick the proper IOL power to leave a targeted post op refractive error. This is not an exact science and the margin of error is +/- 0.50 but INCREASES with high myopia (long eye) or high hyperopia (short eye), eyes with previous RK, lasik, injury or additional eye diseases.
3. Typically the targeted post op refraction is between 0.00 (not needing glasses for distances of 20 feet (6 meter) or more) and -3.00 which has great vision for tiny detail at reading distance 13-14 inches.  Any difference of greater than 1.50 diopter post op may have trouble with glasses (some people tolerate much larger numbers but you never know). The range of relatively clear vision without glasses on is called “depth of focus” and will vary from person to person based on things like pupil size and corneal structure.
4. Some people that are highly myopic or highly hyperopic that do not have cataracts elect to have the lens of the eye removed (same technique as cataract surgery) and an intra-ocular lens (IOL) put in to eliminate thick glasses and improve vision without glasses. It is called "clear lensectomy" or "clear lens cataract surgery” or “refractive lens exchange”. This is done to reduce the thickness of their glasses or make them much more glasses independent.  We are not discussing whether that is appropriate surgery. The IOL and refractive problems are the same as those having cataract surgery.
5. A refractive error that makes some people happy post cataract surgery and often enables them to function without glasses for many things is 0.00 in the dominant eye for distance and -1.25 or -1.50 for the "reading eye." In good lighting they often can read without glasses. With glasses (the RX would be 0.00 distance eye -1.50 near eye and reading add of +3.00 diopters and the type glasses a no line bifocal) The glasses would be worn when best binocular vision is needed e.g. driving especially at night, sporting events or sports participation (gives the best depth perception) and prolonged reading or computer use. (This is called mini-monovision with distance bias)  If a person wanted to shift the clearest vision to intermediate and near (example some accountants, engraver, graphic design artist) the numbers change: -1.25 intermediate vision and -2.75 or -3.00 for reading/near eye. The glasses RX would be -1.25 and -2.75 with +3.00 add in progressive bifocals.
6.   If the person having surgery has astigmatism (aspherical or not round cornea) then the glasses RX will need a "cylinder" lens (second and third part of RX indicated by “cylinder and axis).  The vision without glasses will be less clear due to uncorrected astigmatism.   Assuming our models listed in above example and 1.50 diopters of corneal astigmatism the mini-monofocal distance bias will be 0.00 +1.00 axis 180 and the intermediate/near bias eye will be -1.25 +1.00 axis 180 and a +3.00 add in no line bifocals. This is more blurry vision than 0.00 at distance or -1.25 for near/intermediate.
7. NOTE: glasses can be written in PLUS CYLINDERS OR MINUS CYLINDERS (you can tell which by whether the sign in front of the cylinder number is + (plus) or – (minus) The two formula look very different and prescriptions in plus cylinder cannot be compared with minus cylinder.  Think about your body weight: your weight numbers will look very different whether it is recorded as pounds or kilograms since 1 kg = 2.2 lbs.  A discussion of this subject and the formula for changing plus cylinder to minus cylinders or vice versa is available at   http://en.wikipedia.org/wiki/Eyeglass_prescription
8.  Correction of astigmatism at the time of cataract surgery is desirable.  There are different ways to accomplish this; some are simple while others complex. Some will not generate extra surgical or IOL fees but others will:  placement of incision along steep axis of cornea-make incision larger-use more steroid drops; surgical or laser corneal relaxing incisions; toric IOLs or toric mutifocal IOLs; rounding the cornea at time of surgery with brand new (2013) femtosecond laser; post operatively using  lasik surgery to remove residual astigmatism.
9. In cases where one eye has a cataract that is symptomatic and causing problems with important functions such as driving, reading, recognizing faces, glare avoidance, etc.  but the other eye has no cataract or a cataract that is small and not troublesome in people with large refractive errors special attention needs to be made to choice of IOL.   If targeting of the patient/surgeon desired refractive error post operatively generates a difference in the two eyes greater than 1.50 diopters, the person should know it may be difficult to wear glasses conformably and/or glasses (no line bifocals usually) plus a contact lens on the un-operated eye. Or  lasik or other post-operative refractive surgery may need to be done on the un-operated or operated eye to help them work together.
10. The problems outlined in #9 above may require surgery on the “other” eye to re-establish the ability of the eyes to work together with and without glasses. This can be true even if the cataract is small or even non-cataractous.  
11. So called “Premium” IOLs (toric, multi-focal and accommodating) are used to reduce dependence on glasses. For almost all people they do not eliminate glasses 100% of the time. Even people that consider themselves “not needing glasses after cataract surgery” often wear glasses for special purposes such as night driving and prolonged reading or computer use. Premium IOLs are more expensive, have a greater chance of complication (although in the hands of an experienced ophthalmic surgery the risk is small), and produce unwanted glare and scattered light (dysphotopsia) more than modern aspheric monofocal IOLs.  
12. It is also fair to say that some ophthalmology and optometry offices exert effort to encourage people to “upgrade’ from monofocal IOLs to “premium” IOLs. In sales this is not called “upgrading” but “upselling”. Also it’s important to know that some optometrists receive part of the surgical payment for cataract/IOL surgery, this is known as “co-management”.  Premium IOLs are not better than monofocal IOLs; they are not designed to make everyone 100% glasses independent all the time. Most ophthalmologists and optometrists do present a fair discussion of each type of IOL and let an informed patient make the choice that suits them best.
13. While cataract/IOL surgery is the most common type of surgery done on adults and has a very low complication rate it is not risk free NO SURGERY IS RISK FREE; THAT’S WHY YOU READ (or have read to you) AND SIGN A SURGICAL CONSENT FORM THAT INFORMS YOU OF THE DIAGNOSIS, YOUR OPTIONS AND POSSIBLE RISKS AND COMPLICATIONS. These risks cannot be entirely eliminated. No surgery is entirely “routine and risk free”   Think about driving an automobile. Driving is “routine” to most of us. Yet everyday there are people injured or killed in automobiles. We continue to drive because, with care, the risk is relatively low. Think of cataract surgery the same way.
14. In most all cases cataract surgery is elective. You can take your time and make these important decisions. There is nothing wrong with seeking a second opinion from a different ophthalmic surgeon. You can also access the many helpful discussions on these topics at the two AAO Medhelp Eye Forums by using the search feature or looking in the archives.

15. This information is not meant to give you specific recommendations. This posting is for information purposes only. You should rely on your own multi-source research and discussions with your ophthalmologist, optometrist and personal physician.