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

Specialties: Ophthalmology

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VISUAL SNOW UPDATE: 2018

Apr 16, 2018 - 24 comments

This material is from the April 1, 2018 issue of Ophthalmology Times medical newsletter. The title of the article is "Migraine Pain More Than A Headache" and is based on The Hoyt Lecture given at the 2017 meeting of the American Academy of Ophthalmology by Kathleen B. Digre, MD a neuro-ophthalmologist from University of Utah.

Patients with various forms of migraine have an increased incidence of "visual snow".  NOTE VIP: "The proposed criteria for visual snow that were developed include: dynamic, continuous dots in the visual field for at least three months and the presence of at least two other visual phenomena and palinopsia, enhanced entoptic phenomenon, and at least one of the following: excessive floaters, or 'self-light of the eye' or photopsia, photophobia and nyctalopia.  

As many as 59% of migrane patients may have visual snow. And 87% of visual snow patients have some problem with headaches. 25% of people have had visual snow since childhood.

Treatment is often not necessary as many people learn to ignore the symptoms. Medications that sometimes help: lamotrigine, nortriptyline,carbamazepine and sertraline.  Sometimes glasses with blue/yellow filters or FL-41 spectrum filters are helpful.  The complete article might be available for viewing on the Ophthalmology Times website previous issues this is Volume 43 #6  4/1/18



2018 General Information on Dry Eyes-Now known as Ocular Surface Disorder

Mar 10, 2018 - 12 comments

Dry eyes are one of the most common conditions seen in the practice of ophthalmology. Collectively dry eyes probably cause more eye discomfort and irritation than any other condition.  The term “dry eyes” will never go way but it’s misleading.  Eye MD ophthalmologists now call this “ocular surface disorder” (OSD) and sometimes “tears dysfunction syndrome.”  There are two forms of the problem. In the first (called by Eye MDs ‘aqueous deficiency’) there are no tears or few tears; it is often associated with dry mouth and is the most severe form. In the second form, the eyes water constantly or often. It is called ‘lipid deficiency’ and is caused by eyelid oil gland (Meibomian Gland Disorder or MGD) problems.  In the first form the eye doesn’t make enough tears; in the second form the tears are of poor quality.  There are many tests for OSD, some of them quite expensive, but the diagnosis can usually be made by a careful symptom review and examination of the eye and eyelids. For persistent problems a complete medical eye examination by an Eye MD ophthalmologist is needed plus telling the Eye MD about your symptoms and how troublesome you find them. Self education on OSD is extremely important.

         If you are menopausal or post-menopausal be sure you and your gynecologist maintain optimal hormonal balance. (Many women with dry eyes have dry mouth and dry vaginal canal). If you have joint pain have that evaluated to be sure you don't have Sjorgren's syndrome or rheumatoid arthritis. You might review your medications with your ophthalmologist. Almost any cold, allergy or sinus medicine can cause or aggravate dry eye and mouth. Oil and debris along the eyelids (blepharitis) can aggravate dry eyes. Blepharitis can also cause eyelid infections such as styes, blocked oil glands (chalazion) or eyelash loss and red eyes and eyelids.  Eye lid cleaners and wipes are very useful. They are non-prescription. The easiest to find, and among the best, are Ocusoft products:   http://www.ocusoft.com/ For recalcitrant cases the new prescription Avenova Eye https://avenova.com/ has worked extremely well.

OSD treatment usually begins with use of preserved and/or unpreserved artificial tears during the day and gels or lubricating ointments at bedtime. Environmental modification is important.  Don't belittle eye drops. They are not ‘all the same”. You would never walk into a restaurant and say “Bring many any type of food, it’s all the same.”  There are over 100 different brands of artificial tears and they can't all be lumped together. Sometimes one will find the perfect drop. That means you put the drop in and your eye becomes comfortable in 5-10 minutes and remains comfortable for at least 3-4 hours. If it stings or burns, write down the name on a list you keep and give it a failing grade. If it helps but only for an hour continue your search for one that lasts 3-4 hours; give it an average grade.   YOU MUST KEEP A LIST OF DROPS YOU HAVE TRIED AND HOW THEY WORKED OR DID NOT WORK FOR YOU.

Because the OSD problem is so prevalent the pharmaceutical companies are coming out with new products all the time. Some of the newest are Systane preserved and unpreserved, Optive, Blink, Soothe, and Retaine. Eye drops for dryness are classified as unpreserved drops (individual vials that must be used within 24-48 hrs.), preserved drops, gels and ointments. The unpreserved drops are more expensive and usually only help the small percentage of people that are really allergic to preservatives. Gels and ointments are normally used at night since regular artificial tears won’t last all night.  Ointments are messy and many people dislike them.  Be sure to try Nature’s Tear’s Eyemist a spray for dry eyes that works for many people. It is available without a prescription.  http://www.naturestears.com/

Tears may need to be used as often as 4-6 times/day.  House brand or generic eye drops may work for the mild forms but moderate or severe OSD usually requires newer brand names.  Omega 3, taken by mouth, has been shown to be helpful. Sources include fish oil (which some people have trouble tolerating), creel oil and flaxseed oil.  Environmental modification means not sleeping under a fan, not blowing air into the face (example in work station, cars, planes) and humidifying home and work and sleep areas during dry winter months.

Some activities aggravate both types of dry eyes because they cause the eye to blink less frequently. These include reading, use of any video screen (computer, iPad, iPhone, video games), watching TV, going to movies.  Discomfort can be helped a great deal by looking away from the screen and focusing on a distant object and blinking forcefully 8-10 times. Do this every 15 minutes during these activities. Because of the increasing amount of time young people are spending on computers/phones/tablets/videogaming there is an epidemic of dry eyes in young people: https://www.nbcnews.com/nightly-news/video/studies-excess-screen-time-could-be-aging-kids-eyes-870691907947  (as an aside young people are also developing impaired hearing at a much younger age due to loud music via headphones/earbuds).

      Warm compresses are often helpful.  Hot washcloths may suffice but a much better way is with re-heatable, eye pads available at any drug store. They are relatively inexpensive and way more efficient that hot washcloths. Follow the directions carefully to prevent damage to the eye. Additional things that can help include a diet rich in fatty fish (e.g. salmon, sardines, etc.). Fish oil taken by mouth usually 2 to 4/day has been show to help some patients. Do not start with this many fish oil/day. Start one per day with a meal and every 2 weeks as another to the amount recommended on the bottle. Ask your physician before beginning fish oil.  In addition, there are non-prescription pills for dry eyes available at most major drug stores or by direct order from the companies. Thera-tears formula for dry eyes is probably the most widely used. You can use any search engine to pull up the websites of the companies that see these.

For people that exhaust all these first and second level treatments, whom are still moderately or severely symptomatic and/or who are using drops 4 or more times/day, they might consider Restasis or Xiidra.  These are not artificial tears but prescription eye drops that over a period of 4-6 months: 1. reduce inflammation on the surface of the eye and 2. promote the formation of more efficient, high quality tears.  It is important to realize the commitment one is making when considering these:  1. twice/day for the rest of your life (or until something better comes along) 2. waiting 4-6 months for them to start working 3. expense associated with them (although in the long run may be less expensive than purchasing brand name eye drops to use 4-6 times/day).    You can read about them on their websites:  https://www.restasis.com/  and https://www.xiidra.com/

This is sort of a personal testimonial. I do not receive any money from any drug company for anything.  My wife and I have moderately severe dry eyes. I have aqueous deficiency, classic ‘dry eyes” and my wife ‘lipid deficiency’.  When we did not respond to first and second level treatment we went on Restasis. After 3-4 months we saw some improvement and after 6 months were entirely comfortable with only occasional use of artificial tears. Both of us have been on Restasis over 5 years.  There is a way of using Restasis in non-preserved vials that can dramatically reduce the cost. This method does not work with the multi-drop Restasis bottle introduced the past year. We always ask for the non-preserved vials.  Xiidra is relatively new. They are advertising heavily now using Jennifer Aniston as spokesperson. It is not better than Restasis and in the testing phase in some areas was not as good as Restasis. The company is marketing that its full onset comes 4 months after starting drops whereas Restasis is 6 months. I have not used a great deal of Xiidra in my practice for several reasons:  1. when patients hear how well Restasis did for me and my wife they want to try it. 2. In the few cases I have tried it the patients did not like it and especially 3. when the Xiidra first refill discount cards and samples are exhausted the patients have found it way too expensive.  

New treatments also include pulsed laser to the surface of the eyelids https://www.reviewofophthalmology.com/article/intense-pulsed-light-for-treating-dry-eye  and heat/compression to the eyelids https://tearscience.com/lipiflow/   I do not have much experience with these but patients treated elsewhere have told me they are quite expensive and may or may not prove helpful.

      If you reach a point of exhausting all the above see an ophthalmologist that specializes in "Cornea and External Disease". This is their special area of expertise. A final new treatment that they can often do is “Autologist Platelete-rich plasma” therapy. This uses eyedrops made out of your blood products. (reference Ocular Surgery News: November 1, 2007 page 46 lead author Jorge Alio MD.

     While dry eyes-ocular surface disorder cannot be cured, it is a chronic problem, is can almost always be helped a great deal. The Eye MD can only do so much and much of the success of treatment is determined by the willingness of the patient to learn about the problem and systematically work towards relief of their symptoms.


Marathon Running Done Over Many Years Bad For Heart

May 21, 2015 - 77 comments
Tags:

Marathon Running Harmful



Marathons: In the Long Run Not Heart Healthy
John C. Hagan III, MD & James H. O’Keefe, MD

As the June7, 2014 Hospital Hill Half-Marathon “run up” commences, disturbing research is accumulating about potential cardiovascular dangers of exercising at maximal levels for durations over an hour, especially after age 40.  While this type of ‘excessive endurance exercise’ can occur with cross-country skiing, long distance swimming, triathlons, and 100+ mile bike races, the prototype activity is marathon running.
The first marathon occurred about 2500 years ago by the messenger Pheidippides who ran the 26.2 miles from the plains of Marathon to Sparta there proclaiming the Greek victory over the Persians. History records his first words were, “Joy to you, we’ve won.” Less certain are his last words, perhaps “My feet are killing me” before dropping dead.
Incredibly many physicians and the public have misinterpreted Pheidippides’ fatal run as healthful. In 2014 there are 739 marathons scheduled in the United States and Canada. It is estimated that over a half million people will complete a marathon this year. 100 mile ultra-marathons are common and worldwide months long extreme-endurance races of over 3000 miles exist.

Research published in the April 2014 Missouri Medicine: The Journal of the Missouri State Medical Association, a peer-reviewed medical journal, found that long-distance running over decades of life may cause a greater than normal buildup of calcified “hard” plaque and the more dangerous fatty “soft” plaques in the vital coronary arteries that supply the heart muscle. Lead authors Robert S. Schwartz, MD, of the Minneapolis Heart Institute, and James H. O'Keefe, MD, Saint Luke's Mid America Heart Institute, Kansas City found that long-term participation in marathon training and racing is paradoxically associated with increased coronary plaque volume. Since most marathon runners believe their long hours exercising, sometimes logging over a hundred miles per week for years on end, creates a strong healthy heart, or at least does not damage this vital organ, this new information is perplexing and shocking. Nevertheless, daily and less strenuous exercise remains one of the most important facets of getting and staying healthy.
Regular exercise and high levels of physical fitness are linked to lower risks for cardiovascular diseases and improved life expectancy. Four decades ago Thomas Bassler, MD, an American physician, reasoned that if some exercise was good more had to be better, and famously hypothesized that marathon running confers immunity against coronary plaque buildup and heart attacks. In the current study, Bassler’s theory—long term marathon running protects against coronary atherosclerosis—was tested by quantitatively assessing coronary artery plaque using high resolution coronary computed tomographic angiography (CCTA) in veteran male marathon runners.
To qualify for the study the long distance runners had to have completed at least one marathon each year for 25 consecutive years. The control subjects were a group of apparently healthy men who had never been regular vigorous exercisers but who were similar to the marathoners in age and other general cardiovascular risk factors. The 50 male marathon runners, as compared to the 23 inactive male controls, had increased total heart artery plaque volume, calcified plaque volume and non-calcified plaque volume. Although other medical studies had indicated that marathon running can cause accumulation of the less dangerous “hard” plaque this was the first time “soft” plaque was also found to be elevated. Soft plaque rupture and clot formation is felt to be the most common cause of heart attacks and sudden cardiac death.
Additionally, a Missouri Medicine editorial overview of excessive endurance exercise by prominent cardiologists Peter McCullough, MD, of the Baylor Medical Center, and Carl Lavie, MD, of the John Ochsner Heart and Vascular Institute, conclude that in marathon runners the chronic stress of endurance training for long periods of time may stiffen the heart arteries predisposing them to hardening and becoming partially blocked. Unlike other sports because the heart is pumping 5-8 times as much blood as during rest, marathon runners while training and racing hold this heavy strain on the heart for a very long time without rest breaks.  When this happens, it may stretch the heart chambers and lead to scar formation in the cardiac muscle.  Scar tissue in the heart is the cause of lethal heart arrhythmias and cardiac arrest in some of the highly publicized cases of seemingly healthy marathoners who die during training or long-distance running events. These deaths include 57 year old ultra-marathoner Micah True, also known as Caballo Blanco featured in the best-selling book Born to Run and 52 year old Jim Fixx author of The Complete Book of Running. Both died while running. Boston Marathon winner Alberto Salazar at age 47 was luckier and was successfully resuscitated after sustaining a heart attack while running, collapsing unconscious and without a pulse for 14 minutes.  

Future research is needed to find who is susceptible to having this happen, why, and how can we best train and exercise and enjoy the benefits without taking on life-threatening risks. One such test is a Heart CT Scan.  This relatively quick and painless examination can measure calcium deposits in the heart arteries. These calcium deposits are indicative of plaques in the coronary arteries. A normal value is zero but numbers over a 100 are associated with increasing risks of heart disease including angina, heart attacks and cardiac death. St. Luke’s Hospital offers Heart CT tests for $50 which is usually not covered by insurance. Tests can be scheduled by calling XXXXXX. No physician referral is required.
Exercise might be best understood as a drug with powerful benefits, especially for cardiovascular health. As with any potent drug, establishing the safe and effective dose range is critically important—an inadequately low dose may not confer full benefits, whereas an excessive dose might produce harmful effects that outweigh its benefits. Running marathons for decades is an excessive amount of exercise, predisposing to an increased coronary artery plaque buildup despite favorably altering many risk factors such as weight, blood pressure and risk of diabetes. A more moderate dose of exercise is a better strategy for promoting long-term cardiovascular health and durability.
An example of a sensible and time efficient ‘exercise prescription’ is shown in figure 1. Before starting or increasing exercise programs have a physical examination and discuss your exercise prescription with your personal physician.
Nothing in this new research invalidates that the most important and under-utilized “wonder drugs” for health maintenance are regular moderate exercise, a good diet, body weight vigilance, avoidance of all nicotine use, for those that drink alcohol no more than 2 drinks per day-ideally red wine, drive carefully and always fasten the seatbelt, get plenty of sleep, develop a social network of friends, have a pet─preferably a dog to walk─ and a satisfying spiritual-religious belief system.
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LINK TO SCIENTIFIC PAPERS:

http://www.omagdigital.com/publication/?i=204134  

About the authors:
John C. Hagan III, MD is the Editor of Missouri Medicine and a Discover Vision Centers-Northland ophthalmologist. He is a former marathon runner and current daily walker-swimmer.

James H. O’Keefe, MD is a nationally known preventive cardiologist with the Mid-America Heart Institute at St. Luke’s Hospital, Kansas City. He is a daily moderate exercising runner. He and his dietician wife Joan authored “Let Me Tell You a Story: Inspirational Stories for Health, Happiness and a Sexy Waist” (McNeel Publishing, 2013)


New Article on Multifocal IOL vs "Mini-monofocal" 2015

May 21, 2015 - 35 comments

Mini-monovision Versus Multifocal Intraocular Lens Implantation

Labiris G, Giarmoukakis A, Patsiamanidi M, Papadopoulos Z, Kozobolis VP

J Cataract Refract Surg. 2015;41:53-57

Study Summary

This study was performed by a team of investigators from Alexandroupolis, Greece, who compared levels of spectacle independence and visual symptoms in cataract surgical patients.

Two groups of age-matched patients with no ocular abnormality underwent cataract surgery performed by the same surgeon. One group received a refractive multifocal IOL (Isert PY60MV; Hoya Surgical Optics, Inc.) with both eyes targeted for plano, whereas the other comparative mini-monovision group received a monofocal aspheric IOL (SN60WF; Alcon Laboratories, Inc.) targeted for -0.50 D in the dominant eye and for -1.25 D in the other eye.

Pre- and postoperative evaluations were obtained with the Visual Function Index-14 (VF-14) to determine visual symptoms and general visual functionality. Uncorrected binocular near and distance vision were assessed, as well as the proportion of patients who were spectacle-dependent for near and distance vision.

Both the multifocal and mini-monovision groups achieved good binocular uncorrected distance vision. The multifocal lens provided better overall near vision than the -1.25 D target for mini-monovision. There were no differences between the two groups in contrast sensitivity, stereopsis, or VF-14 items pertaining to distance or near vision.

Approximately twice as many multifocal patients (66%) reported being spectacle free compared with mini-monovision patients (34%). However, dysphotopsia (shadows and glare) occurred much more frequently in multifocal patients than in mini-monovision patients.

COMMENTS: William Cuthbertson MD
Although two thirds of the multifocal group was "spectacle-free" in this study, spectacles are not expected to provide relief from dysphotopsias in multifocal emmetropic patients; therefore, patients would be "spectacle-free" no matter what their visual function.

An additional question that could be posed in these studies comparing multifocal IOLs with monovision would be, "Is your vision adequate to do everything that you want to do with ease, including if you wore glasses when you need to?" If the occasional need to wear glasses is included, the excellent vision without dysphotopsias afforded by monofocal monovision would reflect a very high level of visual satisfaction in virtually all patients.

In conclusion, although the term "mini-monovision" could be better defined for study purposes, the concept of providing proximal-range, convenient, and usually spectacle-free vision with simple monofocal IOLs is very appealing. It maintains justifiable advantages over more expensive, and sometimes problematic, multifocal IOLs.