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

Specialties: Ophthalmology

Interests: Eye-Medical Blog

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General Information on Eye Exams

Dec 13, 2009 - 3 comments

The slit lamp is a bio-microscope usually used to examine the front of the eye. When you are in it your head is against the forehead rest and your chin is on the chin rest.  To examine the back of the eye a hand held lens can be used or one that is attached to the frame of the slit lamp (usually a Hruby Lens).  The most common of these lens is used to see the macula or reading part of the eye. It may or may not be necessary to have someone look in all directions.

Another type of lens can be used with the microscope to check the retina, especially the peripheral retina that is often hard to see and where many holes tears occur. An anesthetic drop is put in the eye and then the lens is put right on the cornea between the eyelids. This type of lens is called a "gonio" lens.

Now to check the retina for tears and detachments the most common method is none of the above. The instrument used is the binocular indirect ophthalmoscope. It looks like a miner's light and goes on the head of the ophthalmologist not the patient. The doctor uses a hand held lens while the patient sits in the exam chair and is usually tilted back. The light is very, very bright even when on the "low" setting. The patient is usually instructed to look up, down, left, right. Sometimes also diagonally in the oblique fields of view. Not infrequently an instrument called a "scleral depressor" is used to press on the edge of the eye to allow the ophthalmologist to see small holes and tears and search for "flat detachments". It is not always necessary to do scleral depression when doing an examination of the peripheral retina.

From your description I cannot tell what "Doctor 1 and Doctor 2" saw. Remember there several kinds of "eye doctors". Your best best to be sure you are competently examined is to see a eye physician (ophthalmologist or Eye MD). Then you are getting the following training: college 4 years, medical school 4 years, intership 1 year, ophthalmology residency 3 years, Fellowship (optional 1 to 3 years). So the ophthalmologist Eye MD will have 12 to 15 years of medical and surgical eye training. The other type of "eye doctors" optometrists have 7 or 8 years of non medical school non surgical training.

General Information on Glaucoma

Dec 12, 2009 - 6 comments

glaucoma is an extraordinarily complex disease. It's actually a whole group of diseases-depending on how you want to classify them there may be as many as 10-20 types. When the word "glaucoma' is used and not further qualified, what is meant is "Primary Open Angle Glaucoma" (POAG) also sometimes call Chronic Open Angle Glaucoma (COAG).

You can't simplify it as you did. You can have glaucoma with pressures less than 20 (lo tension or normal tension glaucoma), you can have pressures over 30 and not have glaucoma (glaucoma suspect). However if damage to the visual field and optic nerve is present then glaucoma is likely present. By the way damage to the optic disk occurs first--so its possible to have an abnormally large and damaged cup/disk ratio and normal visual fields.

Ophthalmologists are extremely excited over a new technology called optic nerve OCT (optical coherence tomography). OCT is a leading indicator. It measures the first evidence of glaucoma damaging the nerve fiber layer of the retina (it becomes thinner). When enough damage occurs the optic nerves starts to get 'cupped" then finally after enough damage is done to the ganglion cells of the retina and the nerve fiber layer (Perhaps as much ad 50% of more damaged) the visual field changes.

You should take heart as ophthalmologists (Eye physicians and surgeons or Eye MDs) have 4 family of drugs to work with that are additive in pressure lowering effect. Within each of the 4 families there are several different brands that can be tried. Then there are two different kinds of lasers (ALT of argon laser trabeculoplasty and the newer SLT or selective laser trabeculopasty) to try is drops don't work or if the patient cannot put drops in their eyes. Lastly there are several types of traditional surgery usually called "Filtering" surgery that can be used.

You should take heart. Most cases of glaucoma can be controlled one way or another. Most of the people that go blind due to glaucoma either were not diagnosed until most of the optic nerve was severely damaged or are non-compliant and don't use their medications or keep their appointments to see their ophthalmologists.

Your use of your eyes has no effect on your eye at all. It will not cause glaucoma or any other eye disease. Perhaps some eye strain or watering but never, ever will it cause glaucoma, cataracts or physical damage.

JCH III MD Eye Physician & Surgeon

2B or Not 2B: Flying In the Age of Innocence

Dec 12, 2009 - 5 comments

2B or Not 2B: Flying in the Age of Innocence
Missouri Medicine Editorial #12
John C. Hagan III, MD

“Is there is a doctor on the plane? Please come to the First Class cabin”
I’m an Ophthalmologist, in a plane 30,000 feet over the Atlantic Ocean, returning from a much needed winter vacation. It’s 1995, the world and air travel were different then.
We’re halfway between Puerto Rico and our Miami destination. There are more than 200 people aboard this Boeing 747. I’m rapidly calculating the odds that there’s an Emergency Medicine specialist or Internist on board.
The announcement is repeated, a little more urgent, the voice noticeably more desperate.
“We need a doctor in first class. Pause. The female announcer draws a deep breath. Any kind of doctor will do.”
Heads are turning expectantly back in cattle-class where my wife and I are traveling. As yet, no Good Samaritan has stepped forward from the hoi polloi. The woman on my left murmurs, “I’m a registered beautician. I worked one summer as a lifeguard. Maybe I should see if I can help.”
It occurs to me that if someone is drowning in a martini or having  a bad hair day, she would be just the ticket.
“John, you have to go. There’s no other doctor on the plane,” my wife opines. I have reluctantly arrived at the same conclusion.
Marshalling my best bravado and sang froid, I head for the First Class cabin. Rapid pulse, perspiration, dilated pupils-I exhibit all the symptoms of a full-blown “fright on flight” reaction. Bladder and bowel control suddenly become an issue.
More eyes than I examine in a week follow me down the aisle. Bits of conversation catch my ear.
“Why did he wait so long to stand up?”
“Maybe he’s hard of hearing.”
“Maybe he’s a pathologist.”
After what seems like a mile and a half, I reach the front of the plane.
There I meet the flight attendant with the edgy voice.
“I just can’t understand it. We always have a doctor in First Class. We never have to go back there  in an emergency”.
This elitist flight attendant whom I dub ‘Queen B’ has spent too much time in first class. The caviar fumes have damaged her brain.
Why are there no physicians traveling First Class? She understands nothing about doctors’ favorite oxymoron-Medicare reimbursement.
“You’re a doctor?”, Queen B asks suspiciously.
“Yes, I’m an Ophthalmologist.”
“Well you’ll have to do. The man in 2B is having chest pain.”
I was really hoping for a corneal abrasion or a hard to remove contact lens.
I try to recall all the specifics of cardio-vascular resuscitation. Just as I’m ready to order boiling water and clean sheets, I remember that’s only for obstetrical emergencies in cowboy movies.
2B is a man in his 70’s. Like his attending physician, he is gray and sweaty.
2B’s wife, 1B, says her husband has angina. They ran through the San Juan airport to catch the flight.
It’s been a long time since I managed a chest pain patient. Do I apply leeches or ‘bleed him’? Just kidding- hasn’t been that long.
“Where are his medications? ”, I ask.
“Up there,” says 1B, pointing to the overhead storage, “in our carry-on luggage.”
I stand up to open the overhead bin.
“Careful” Queen B says sharply, “shift happens!”
Chastised, I carefully retrieve 2B’s medications.
After some oxygen and nitroglycerine, 2B is pink and his chest pain has abated. He expresses an interest in lunch. I realize I’m the only passenger that’s still gray and sweaty.
I’m about to ask 2B to share the oxygen when Queen B says the Captain wants to see me. I’m escorted to the cockpit door, which opens after a series of knocks and a code word.
Queen B introduces me to the Captain. “This is the doctor, (pause) but he’s an eye doctor (zing)”
I step inside the cockpit.  “Wow” I gush, “what a great view you guys have up here.”
“That’s why we drive it from up here, doc.”
I realize I have just blurted out a candidate for the Inane Comment Hall of Fame.
The captain wants to know the details. I tell him things are going well, 2B has probably only had an angina attack and he seems to be back to normal.
He thanks me. Queen B asks me to return to my seat and reminds me to fasten my seat belt.
As I retreat through First Class I notice how much more appetizing the food looks. Back in coach, cold ‘mystery chicken’ awaits me.
I find 2B off oxygen and enthusiastically discussing wine selection with 1B.  
“Thanks for the help, doc. My wife could never have got those medications out of our carry-on without you. Are you really an eye doctor?”
“Yes, I’m an Ophthalmologist”
“Do you have one of those little tiny screwdrivers that tighten glasses frames? Mine are kind of loose.”
“No,” I say, “I’m on vacation and traveling light.”

General Information on Myopic Macular Degeneration

Dec 12, 2009 - 0 comments

The use of scleral reinforcement for treatment of progressive high myopia is not a procedure universally agreed by ophthalmologists to be appropriate for the high myopia condition. Moreover there are only a few centers that do this procedure on a regular basis. This is an appropriate reference for you to read about the procedure. Cut and paste into your internet browser:  http://www.mdsupport.org/library/degenmyopia.html

The laser you had would not cause cataracts or progression of your myopia.

Cataract surgery, even successful, small incision phacoemulsification will increase the risk of a retinal detachment significantly. Thus you should not take this risk until your vision is a "big" problem and the cataract is the main cause. Also the ophthalmologists (Physician Eye MDs) will put an intraocular lens in your eye to correct your high degree of myopia so that after the procedure you likely will not need to wear contacts and your uncorrected vision at distance and mid range will probably be better than its been for most of your life.

If you have one eye 'fixed' then your eyes will be quite optically unbalanced (high myopia in unoperated eye and near normal vision without glasses at distance). This will be to much for even contact lens to correct. So when you have one eye fixed, after it's healed and things are stable (4-8 weeks) you will need the other eye done.

The implant should be placed in the posterior chamber not the anterior chamber.

Please use the search feature on this web page to search "multifocal intraocular implants", "Restor implant", Resume implant and "crystalens" implants. There are a lot of postings on the two eye forums with problems with multifocal implants. As a generalization I would advise against the use of a multifocal implant and plan on wearing no line (progressive) bifocals. An alternative would be contact lens using mono-vision or bifocal contact lens.

The AREDS study showed that takeing a multivitamin plus a special combination of extra vitamins reduced the progression of dry macular degeneration in moderate or severe cases by 23%. It did not seem to help mild macular degernation. There were few test subjects without macular degeneration and the supplements did not have lutein. The AREDS study is being repeated on patients without macular degeneration using a similiar forumula but with about 10 mgms of lutein added. This study unfortunately will not be concluded and published for several years.

Myopic macular degeneration is not the same as age related macular degeneration. There are no studies to advise you about what supplements might be helpful for your problem. All the supplements you mention are "okay" except Gingko Biloba. It has not been helpful for eye conditions, has documented multiple side effects including bleeding tendencies.

Your retinal specialists are the best source of specific recommendations for you.

Best of luck