Myopic degeneration/lacquer crack

[wwhmustaine]

I was recently diagnosed with myopic degeneration in my right eye, and told that I have a lacquer crack in that eye. I am 40 years old, and as a practicing attorney, am obviously concerned that my condition will either worsen in my right eye, or also develop in my left eye, thus rendering me essentially disabled.  Is there any treatment, therapy or surgery available for my condition? If not, what are the best preventative measures to take to ensure the condition does not progress in my right eye or begin develop in my left eye?  Lastly, what is the likelihood that the condition in my right eye will worsen, or that it will also develop in my left eye?  In other words, is it likely that I won't notice any significant decline in my condition over the next few decades?

[John C Hagan III, MD, FACS, FAAO]

There is no treatment for "Dry" myopic macular degeneration or lacquer cracks. However either of those can lead to "wet" MMD due to the development of choroidal neovascular membranes. ther treatment for that is intraocular lucentis or avastin or photodynamic therapy.

I cannot quantitate the risk.  If the other eye is myopic the same amount the risk of the problems occuring there are likely between 20 and 40%..

JCH MD

[wwhmustaine]

Thanks for the reply, Dr. Hagan.  

My right eye (where the problem is) is -8.5, and my left is -7.5.  Does this mean that the chances, over time, of the same problem developing in the left eye would be less than the 20% to 40% that you cited?

This may require pure speculation, but is there anything on the horizon that could eventually serve as effective treatment for this condition?

Lastly, should I expect the problems in right eye to worsen over time, and are there any preventative measures I can take to guard against this?

Thanks again.

[John C Hagan III, MD, FACS, FAAO]

I would say the -7.5 would be toward the low end and the -8.5 towards the higher end.

Avastin and lucentis are new treatments and a huge improvement over older methods (laser for example) for treating "wet" NV..  

There is longstanding studies on how to try and prevent high myopia. Long term use of atropine eye drops is under study. Other than that I'm not aware of anything else.

JCH MD

[wwhmustaine]

"I would say the -7.5 would be toward the low end and the -8.5 towards the higher end."

I'm not sure I understand what you're saying.  My right eye is -8.5, and that's where the lacquer crack is. As a result, that's the eye where I have blind spots, straight lines appear curved, etc. My left eye (which is asymptomatic) is -7.5.  I guess my question is this: How likely is it that a lacquer crack (assuming this is what's causing the problems) develops in my left eye? Is it the 20% to 40% you cited, or would it be lower than that?

And with proper maintenance and prevention (Preservision with lutein, fish oil supplements, multivitamin), is it more likely than not that my bad eye won't get any worse than it is now, or should I expect it to get worse over time?

Thanks.

[John C Hagan III, MD, FACS, FAAO]

Because the eye is less myopic it would be closer to 20%.

There is no research like that done on age related MD that diet, fish oil and AREDS vitamins work. Nevertheless its important to do what you can to avoid ARMD in addition to myopic MD.

JCH MD

[wwhmustaine]

One last question, then I'll leave you alone: My RS suggested that over the next few weeks/months, as my brain "adjusts" to the deficits with my right eye (unfortunately, this is my dominant eye), my overall vision may actually somewhat improve, i.e., the left eye will begin to compensate for the right eye.  Also, he says the headaches should stop.

Do you agree with these opinions?

The thought that my vision is as good now as it will ever be is more than a little disheartening, and the prospect of having to live the rest of my life with this condition is overwhelmingly depressing.

Again, I thank you for your time and insight.

[kg17]

I, too, am 40-years-old and suffer from degenerative myopia (-17 bilaterally); have laquer cracks, atrophic damage, blind spots, reduced color vision, reduced BCVA.  I would suggest that you read "dukey's" posts as he has provided extensive research on the topic here on this forum.

Dr. Brian Ward in California is a leading expert in degenerative myopia (there are very few) who has refined a surgical technique called posterior pole buckling which is intended to arrest the myopic progression and thus, halt subsequent damage.  He just published a peer-reviewed paper on the technique - you can locate the citation using Pubmed.  Dukey is, or has, just shortly had the procedure done on one eye and will post his experience as soon as he is able.  Most retinal specialists will just monitor your condition, treating complications as they arise.  But Dr. Brian Ward is actually providing a tx that addresses the cause.  If able, you might want to seek consultation.

[John C Hagan III, MD, FACS, FAAO]

I am not in a position to agree or disagree with your RS who should have the best opinion available. Neuroadaptation may help you ignore some of the blur or distortion "metamorphopsia"

KG17 and Dukey are both helpful and knowledgeable.

JCH MD

[wwhmustaine]

Thanks for the reply. I see that you're a pediatric neuropsychologist, and I assume that you're still practicing. If so, and if you don't mind me asking, have you been limited in what you've been able to accomplish professionally?  Does your condition affect you on a day to day basis?

I was diagnosed with this just a week ago, and my symptoms only began a few days before that. As an attorney, I spend basically all day every day reading, and at this point, it's a real struggle just getting through one day. Hopefully, my eyes/brain will adjust to this (neuroadaptation) and my vision will improve, because to be honest, I can't imagine having to deal with this for the next 30 years or so I'll be working. Furthermore, that assumes my conditions remains the way it is currently.  

I guess I'm just looking for some hope right now.  

Thanks.

[John C Hagan III, MD, FACS, FAAO]

-

[kg17]

I truly understand your despair and disheartenment.  I received the myopic degenerative diagnosis two years ago when I was having multiple symptoms.  Like yours, my profession is also visually intensive.  Due to significant eyestrain, headaches, and fatigue, I've reduced my work hours to a more manageable 25-30 instead of the 50 I did previously.  I rarely drive and then only to very familiar locations.  I've also readjusted my long-term goals in my profession with the realization that my vision is at high risk for further deterioration.  

Neuroadaptation is a real phenomenon and can work to your benefit.  Time is your greatest ally and you can facilitate the process by trying to reduce your anxiety as much as you can - try to go on "autopilot."  Don't focus on the visual aberrations so that the brain can learn to "ignore" or adjust for them.

You might seek the help of a low vision specialist.  Even though you might not "qualify" for low vision services thru state help, a low vision expert can offer some helpful tips to enhance your vision, reduce eyestrain and headaches, etc.  For example, adjusting the lighting and using "natural" light can help immensely.  I am able to read when I have my back to the window as opposed to trying to read under flourescent lighting.  I've also found that reading my professional journals on the computer is easier as I can adjust the contrast and font size.  Whenever possible, I scan documents into my computer and read them.

If you can, seek out a consultation with Dr. Brian Ward.  He may be of some assistance to you.  At the very least, find a very competent, highly regarded retinal specialist and stay under his/her care.

[John C Hagan III, MD, FACS, FAAO]

I wanted to add that the treatment of keratoconus where the cornea is structurally weak and bows forward in a "cone" shape is undergoing a transformational treatment with riboflavin cross-linking. Riboflavin is dripped on the cornea then "hardened" with a special light. Several studies are very high on the procedure and it should become the standard RX in the next few years and hopefully eliminate the need for corneal transplants.

My understanding is that researchers are now trying to see how the same or similiar procedure might be done on the back of the eye to strengthen the sclera. So there is hope and this is research.

JCH MD

[kg17]

I have read the abstracts on these studies using ribroflavin and UV light for scleral strengthening.  My own personal dilemma is whether to opt for surgical intervention (e.g., posterior pole buckling) that is available now, or whether this other treatment is far enough along as to be available in time to help me.  I certaintly don't want to subject my eyes to any more surgery, but at the same time, doing nothing does not seem to be helping the situation either.

Any thoughts?

[John C Hagan III, MD, FACS, FAAO]

I have no experience at all with myopic scleral buckling. Never taken care of a patient that had it done. I don't keep up with the literature over and above what I need to answer first order (easy) questions about the procedure. I do not know enough to give you an answer. I am really sorry I can't be of more help but one thing I've learned over the years that saying "I don't know" is better than a guess or an incorrect answer.

I do wish you the best of luck. Perhaps some of the"experts" in the field can help you.

JCH MD

[kg17]

Thank you.  I have much respect for professionals (e.g., physicians) who can say, "I don't know."

I will keep seeking out info. and stewing over this dilemma.

[John C Hagan III, MD, FACS, FAAO]

-

[dukey]

Sceral cross-linking is 10 years away according to the inventor of this technique following personal communication with him sometime ago, possibly sooner in Europe. I believe I wrote about this treatment on this very forum months ago. There are also recent studies suggesting it could lead to some problems in the retina as it is a fairly risky procedure so time will tell on that. I'm 50/50 on that one. I think buckling is the future with new materials, it works great for RD, no reason it can't work in myopia.

wwhmustaine, I will say what no-one else will say to you. Probably it will get worse for you, most likely you will develop some further complications and you will be alarmed at how fast it can happen. And it will probably affect the other eye to some degree. It is rarely symmetrical though and it is highly heterogeneous and unpredictable. The classic progression is one of small declines followed by long periods of stability, losing small amounts of vision each decline. Even an highly experienced myopic specialist (there are none btw) could tell you which path you will take. The best predictor is your stahpyloma and how deep it is period. You will for sure have one, no question, and if your doc says you do not, walk out and find someone else. Your Rx is essentially irrelevant now. You will learn to talk in axial length and not minus numbers.  


Kg17, I really do not know why you are waiting any longer. I really don't.  

[John C Hagan III, MD, FACS, FAAO]

-

[wwhmustaine]

When you say "staphyloma," are you talking about posterior staphyloma?  If so, how would I discover if that applies to me, and if so, to what degree? I haven't heard a dr. mention that, nor have I seen it in any of my records.

Also, you seem pretty sure that my condition will worsen, which is the exact opposite of what the opthamologists who have seen me said. Their opinion is that while it could conceivably worsen in my right, or develop in my left, neither is likely to happen.  In fact, the RS I saw yesterday (I'm currently 20/20 in both eyes, even with the blind spots and wavy lines in the right eye) said that my condition is not a progressive one.  There is no leakage at this point, and no reason to expect any. And when I asked about sceral buckling, was told that this applies only to detachment, which is not an issue with me.   It is possible that my condition is different from yours and kg17's, as based on my research, I should not expect my problem to get worse.  I'm not arguing w/ you, bear in mind, I'm just curious as to why you seem so sure that things will go downhill for me.  Also, I want to make sure you're saying that pole buckling would be a viable option.

Lastly, do you know anything about FSM, or frequency specific microcurrent? I've heard that improvement is a real possibility with this treatment.

Thanks.

[kg17]

The retinal specialists that I've seen have said much the same to me.  However, lacquer cracks are a classical symptom of myopic degeneration and while your condition may remain stable for many years, the odds are more in favor of problems as you age.  The beginning stages of posterior staphylomas are very difficult to discern on physical exam for run-of-the-mill retinal specialists or general ophthalmologists.  I'd recommend the book "The Myopias" by Dr. Brian J.Curtin if you'd like a basic text.  

For me, the nail that hit me on the head was when I had a multifocal ERG done by a neuro-ophthalmologist that clearly showed that the photoreceptors in my retina were functioning at least two standard deviations below norm, with many patchy areas of "dead" zones.  That was scary.  There's not much "reassurance" that a retinal specialist can provide me after that.  I'm in process to pursue the posterior pole buckling.  Hoping for a good poker hand in the future doesn't seem like a good plan at this point.  Posterior pole bucklling is NOT scleral buckling for retinal detachment, and I don't believe that ophthalmologists or retinal specialists know anything about it except for Dr. Brian Ward in California.  It isn't mainstream treatment right now.

I understand that you'd like to believe that you are okay.  But I think Dukey's right.  

[wwhmustaine]

Thanks, kg17.

I've made an appt. with Dr. Ward for next month, so we'll see what he says.

[nickppatel]

Assume that someone with extreme myopia has no degenerative changes or at least has minimal degenerative changes.  She has a staphyloma.  She gets posterior pole buckling and the axial length stops changing, and the staphyloma stops deepening.  I understand that degenerative changes can still occur due to the axial length that is already present.  Can either of you comment on why this happens?  I assume it's because of aging, but I'd think that stopping axial growth, combined with new therapy for CNV, would be TREMENDOUS in minimizing any problems and preserving good vision for life.

[kg17]

Dukey has the background in molecular biology so he probably has a much better understanding of this processes than I do.  However, I would liken it to the mechanical forces that are present when cement is stretched due extreme heat - it cracks under the physical pressure.  When the retina is "stretched" (extreme axial length), all the various cellular and vascular structures are mechanically stretched beyond what it can reasonably tolerate, thus resulting in its "degeneration."

[dukey]

Yeah kg17 is right and it really is quite simple. if you put any kind of pressurised sphere under those kind of forces, eventually something is going to give. The human body is a remarkable thing and honestly it is amazing that it takes, on average, 20-30 years before symptoms appear.  

The issue with the buckle procedure is that there is a fine line between reinforcing it too much and not enough. If you don't put enough tension behind there, you risk doing nothing to stop the elongation. If you put too much pressure on the macula, all kinds of problems can occur, many of which can be quite nasty. It is true that in most cases the axial length is not significantly reduced by the current procedure but in almost all cases, it does not get longer either. Therefore you are still left with an abnormally long eye and you still have all the problems with that. If you catch it early enough though, the idea is that you limit the extent of degradation because you prevent long term (>20 years) axial elongation. I think only time will tell how effective it really is.  

Note that many years ago some surgeons heroically (and very aggressively) tried to shortern the myopic eye using a technique called scleral resection. The outcome was disastrous for lot of the patients, some of who went completely blind due to massive bleeding etc. Not good!