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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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Missouri Medicine medical journal Editor
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New Cannabis Article from NORTH Magazine July/Aug 2014

Jul 20, 2014 - 0 comments

DON'T LET MISSOURI GO TO POT: THE CASE AGAINST EASIER MARIJUANA ACCESS

At one time asbestos used in school construction, doctors recommending cigarettes to soothe sore throats and putting cocaine in soft drinks seemed like good ideas. Now we can only wonder, “What were they thinking?”  Perhaps we can forgive our forebears because scientific evidence of the cancer causing properties of asbestos and tobacco and the addicting and health destroying nature of cocaine was not in existence at the time. That is not the case with marijuana.
Its unlikely future generations will absolve us of responsibility if the recreational and medical use of marijuana becomes national. The number of states permitting medical marijuana (23) and recreational cannabis for adults (Washington and Colorado) continues to increase. Short summary—bad idea!  As research physicians we present the known adverse health implications of marijuana use.
While generally mellow, marijuana users only seem to become angry and agitated when any suggestion is made that their pot use might have adverse consequences. When we wrote on this subject in the Kansas City Star, they had to shut down The Star website discussion because of all the abusive and vulgar postings. It’s obvious that stoners would rather get mad than carefully consider any contrary evidence to their mental construct that chronic marijuana use is harmless fun.
The high growing cannabis plant has been used commercially in the United States since colonial times when it was imported from Caribbean countries. It was refined or spun into cloth, ropes, wax, resins, paper, fuel, pulp and other useful products.  The Caribbean natives were aware of the psychoactive effects of smoked hemp which they called “ganja”. Presently smoked cannabis plant is also known by many monikers most commonly:  pot, weed, Mary Jane, reefers, roach, buds, joint, green, and back to its original roots—hemp and rope.  
The potency of present day marijuana is from 5 to 20 times stronger that the hippie “grass” used in the 1960’s. That increases the habituating and addicting properties of tetrahydrocannabinol (THC) the major cannabis psychoactive ingredient. This accounts for the rising annual number of emergency room visits (400,000+) for panic attacks, acute psychosis and toxicity.  A review of medical and mental damaging effects of marijuana can be found in Missouri Medicine 2012. Suffice here to say that THC is especially dangerous to children under age 15 and increases the incidence of mental health problems, in some cases the risk of Schizophrenia is increased 10 fold compared to the general population. Ambition and drive is blunted, memory impaired and IQ may be reduced permanently by as much as 8 points. Driving and working while using marijuana dramatically increases the chance of accidents and injuries.
The rapidly expanding commercial marijuana industry e.g. the profitable California based Medbox Corporation, has already produced cannabis food (marijuana laced brownies to be sold in vending machines) and candy like cannabis concoctions with names like “Pot Tarts” and “Kif Kat Bars” that  appeal to youngsters.  Deaths have occurred in children who overdosed on ‘cannabis candy.”
As we reported in Missouri Medicine, “Proponents of cannabis use argue that smoking cannabis provides relaxation and pleasure, enhances the sense of well-being, contributes to stress relief, and helps to deal with hard reality. Of course any enhancement of well-being in a mentally healthy person through use of a psychoactive substance is in some sense an oxymoron. Furthermore, cannabis use alters cortical dopamine, which plays a major role in higher cognitive functions, working memory, executive function, etc. Hence, the “relaxed” feeling most cannabis users report as a desirable acute effect, in all likelihood reflects cognitive dulling (non- or a-motivated syndrome) caused by altered cortical dopamine balance. In other words the weight of evidence indicates that cannabis creates cognitive dulling rather than reduction in anxiety, indifference rather than relaxation, and amotivation rather than inner peace, all closer to psychopathology than well-being.”
Numerous medical studies have shown that chronic marijuana use can permanently impair memory, intelligence, coordination, driving ability, impulse control, damage the heart, lungs, immune system, liver and increase the risk of certain types of cancers. The younger the user and the more frequent the use of marijuana the more potential for serious health problems.  Australian psychiatrist David Castle, MD filled a 252 page text (Marijuana and Madness, 2nd Ed, Cambridge Press) with carefully referenced studies on physical and mental disease caused by marijuana. There were 49 respected contributing scientists from all over the world.
Already over 400 chemicals have been identified in marijuana including carbon monoxide, hydrogen cyanide and ammonia. “Hey man, you want a drag of cyanide and ammonia?” might not find as many takers among the tokers when the roach makes the rounds at parties.
The FDA and physicians rightfully consider cannabis a drug and subject to federally stipulated rigorous study protocols. The legislative route being used to introduce medical and recreational marijuana illegally and dangerously circumvents this FDA drug testing process. Federal law also mandates that marijuana use and possession is illegal but Presidents and the Justice Department have chosen to ignore the laws they swore to defend.
Legitimate FDA type research has been done on purified cannabis and useful products for cancer chemotherapy such as Marinol® and Cesamet® are available. These drugs do not produce psychoactive effects. The use of marijuana products such as “Charlotte’s Web” for childhood seizures and other illnesses is unproven, anecdotal and potentially harmful. Cannabis use for glaucoma treatment is never needed. Medical marijuana “cards” are widely abused. Searching on Google “How to fake needing a medical marijuana card” offers 871,000 helpful suggestions. The most frank and succinct being, “Like man you tell them you got pain. Every dude has pain. Pain work every time!”  
Although dependence and addiction to alcohol and nicotine are among Missouri’s biggest social and health problems, the legal use of booze and cigarettes are cited by marijuana activists as reasons to legalize pot. Less than 8% of Americans smoke marijuana while 52% use alcohol and 27% smoke nicotine cigarettes. Missouri has over 10,000 tobacco related deaths per year. Addiction and abuse of legal medications are more of a problem than illegal drugs.  Deaths from legal drug overdose exceed the number of deaths from automobile accidents and surpass all types of illegal drug deaths combined.  It is catastrophically illogical to introduce another public health problem and source of habituation and addiction to our already overwhelmed health and social welfare systems.
How should one account for nanny-state social planners and big city politicians demonizing sugar, banning trans-fats and large size soft drinks while giving marijuana a pass? Why does the bent-out-of-shape crowd  rail at ‘Big Tobacco, Big Food and Big Pharma” while ignoring “Big Weed” (e.g. CannabisInvestments.com) gearing up to make stores peddling smoked and eaten marijuana as ubiquitous as Starbucks and Subways?  Revenue from taxing marijuana has failed to achieve projections.
As physicians we regard recreational and sham-medical marijuana as a looming public health problem with adverse consequences that could eventually rival those of tobacco use and alcohol addiction.
Washington and Colorado are now conducting de facto social and scientific experiments on the problems of   widely available medical and recreational marijuana. Let’s wait at least five years to assess their results. Let’s stay off the “high” way.
Reference
Svrakic DM, Lustman PJ et al. Legalization, Decriminalization & Medicinal Use of Cannabis: A Scientific and Public Health Perspective. Missouri Medicine 2012; 109(2)90-98


THE RISKS OF MARIJUANA ARE MANY AND SEVERE

Dec 04, 2013 - 45 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 - 9 comments
Tags:

Surgical Whitening procedures

,

Eyeball "bling"

,

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

,

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.