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

Specialties: Ophthalmology

Interests: Eye-Medical Blog
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General Information on Intraocular Lens Power Determination

Dec 11, 2009 - 2 comments

Hello Garrett,    Your mother's optical situation is not uncommon. Choosing an intraocular implant (IOL) power to give the best vision unaided by glasses is as JodieJ says not an exact science. It is much, much better than 5-10 years ago and it will be better 5-10 years from now. It will never be 100%. Like much of medicine we are sometimes a victim of our own success. There was a time in which patients were happy to go through a cataract operation without a major complications and wore regular glasses happily after surgery.

As we have been able to improve the vision without glasses some people expect to see perfect without glasses even though this is not possible for many people and something an ethical surgeon never promises or guarentees.  There are many variables (radius of curvature of the cornea, axial length of the eye, position of the IOL in the eye, etc) that can cause the actual result of surgery to differ from the "theoretical" values used in the pre-operative calculations. There is not even one forumula that surgeons agree is "best" to use for the calculations. As eyes become longer than normal or shorter than normal the possibility of under/over correction increases significantly.

Some eyes, because of astigmatism, are not correctable with the standard monofocal implants used in most surgeries. Even with the new multifocal "premium" IOLs that are used to try and get away from glasses completely for all distances often require glasses for certain tasks and certain distances (use the search feature and look at all the complaints).

Of course it is possible to have  gross miscalcuations due to error in data acquisition or data entry. These are rare compared to the normal "scatter".

Wearing progressive bifocal lens to achieve good vision is the expected and hoped for result of standard monofocal IOL surgery. Some people will see satisfactory at distance without glasses, others will see okay at near or mid range without glasses but this is a bonus not the expected result. We never tell our patients that they will be able to go without glasses. We tell them it often happens but we expect they will need glasses. Period.

There are certain circumstances in which if the difference is way to much to wear glasses (say a 4-5 diopter difference) that the information can be sent to a Medicare review or insurance review committee to authorize a LASIK procedure and have it paid for by insurance/Medicare (of course deductibles or co-payments would legally have to be collected). If glasses are feasible and wearable do not expect them to authorize the LASIK.

As to your physician's behavior, again Jodie J may be right. If you've gone to this ophthalmologist (Eye MD) for quite some time and he/she is generally even tempered and patient, I would cut them some slack. On the other hand if the physician is usually this way then I would seek not only a second opinion but a new ophthalmologist. I am a very patient physician and very even dispositioned but I have "lost it" on a few occassions with my patients. I always felt terrible afterwards and in most cases have called back to apologize the next day. More than one of these occured during a stretch where in addition to my professional responsibilities I was taking care of a sick parent and another member of my family was seriously ill.

Compared to some of the really serious sight threatening complications that are often posted here I think your mother has some really excellent options.


General Information on Fuchs' Corneal Dystrophy

Dec 11, 2009 - 1 comments

There is no exact definition of how many guttatta it takes to diagnosis Fuchs' Endothelial Corneal Dystrophy. Some guttatta are part of aging and do not ever become a problem. Two tests that are often helpful are corneal endothelial cell counts (the number decreases as the disease develops and progresses) and corneal pachymetry (corneal thickness) the thickness increasing as the disease develops and progresses. Family history is useful as many cases of Fuchs' are hereditary (affecting females more than males). Guttata are 'bumps' that develop on the back of the cornea when there are not enough endothelial cells to cover it. These cells are very important as they pump fluid out of the cornea and into the anterior chamber of the eye. The cornea is hydrophilic (water loving) like a sponge. When it swells and gets thicker it starts to become cloudy and blur the vision. When this happens and the impairment is severed than a corneal transplant is indicated. Recently a new operation for decompensated Fuchs' dystrophy called DSEAK (Descemet's membrane epithelial automated keratoplasty) has dramatically speeded the healing, safety and results over full thickness penetrating keratoplasty. Corneal endothelial cells do not multiply or replace themselves when damaged or cell death occurs.

Cataract surgery will not cause Fuchs' dystrophy but cataract surgery (or for that matter any surgery inside the eye) will stress the cornea and in severe Fuchs' could be the final straw that causes the cornea to compensate.

Your doctor is absolutely correct. In my patients with progressive Fuchs's dystrophy I recommend cataract surgery SOONER rather than later because the advanced, "hard" cataract will put much more stress and strain on the cornea endothelium than a moderately firm or softer cataract. Fuchs' dystrophy can decompensate on its own without any surgery taking place or any cataract in the eye.

It would be helpful to know if your mother's problem with her eye's was Fuchs' dystrophy. It is unusual for Fuchs' to cause an eye to be removed, so there's a good chance she had something else.

I would go ahead and have the cataract surgery when your vision starts to be a moderate problem for you and the cataract is the cause. By using the endothelial cell count and corneal thickness, your ophthalmologist can give you a reasonable risk of the cornea being able to stand your cataract surgery.

Good luck, new cataract surgical techniques are much, much more gentle on the eye than techniques used in the past.


Information about Eye Muscle Disorders (Strabismus)

Dec 11, 2009 - 4 comments

Strabismus Treatment

Hello, Eye alignment disorders/diseases are called "strabismus" by Ophthalmologists. If the misalignment is the same in all directions it is called a "commitant" deviation; if the misalignment varies in different directions, or (as in your case) is present in only certain directions it is an "incommitant" deviation. Misalignment problems are either vertically or horizontally (as in your case) misaligned or both. If the eye are deviated towards one another ('cross eyed) it's an esotropia or convergent strabismus; if the eyes deviate away from one another it's a divergent or exotrophia ('wall-eyed'). Thus you have an incommitant deviation, probably a esotrophia. (I would have to examine you to be certain).

Commitant deviations are usually due to problems with the control centers ("fusion centers") in the brain and are usually present at birth or develop in childhood. Incommitant deviations are usually due to weaknesses of one or more of the 6 extra-ocular muscles that move each eye (12 all totaled). While they can be present at birth they are more likely to develop in adults and may be caused by trauma, diseases, injuries, etc. Because the nerves that elevate the eyelids and that make the pupil larger and smaller are located near the control centers for the extra-ocular muscles incommitant strabismus may be associated with a droopy eyelid, and pupils that don't work right.

Of the 6 extraocular muscles that move each eye four move the eye up and down (superior rectus, inferior rectus, superior oblique and inferior oblique) and two move the eye horizontally (medial rectus, lateral rectus).

When you look to the right you're using your right lateral rectus and the left medial rectus. Your description of your problem would implicate one of these two muscles as the cause of your problem. It would also be important to know if when you look right or left whether your upper and lower lids in either eye move up or down. A not infrequent cause of a problem like yours is called "Duane's Syndrome", a second would be a left lateral rectus palsy.

Prisms glasses do not work well on incommitant strabismus. You need to see a Pediatric Ophthalmologist. They are the strabismus experts of the profession of Ophthalmology. They have extra training in eye muscle problems; although most of their patients are kids almost all of them do adult strabismus.

Because you used your eye care insurance and were given prisms, I suspect you saw an optometrist. A Pediatric Ophthalmologist is a physician (MD) that has been to medical school and taken an extended Residency (EyeMD). Because you have a medical problem your evaluation should be covered under your HEALTH insurance. You can check with your insurance carrier to confirm this or you can call the Pediatric Ophthalmoloist you're going to see and confirm that they participate in your plan. Almost all major cities have Pediatric Ophthalmologists and they can also be found in the Department of Ophthalmology of all medical schools and on the faculty of most Children's Hospitals.

Many of the important diagnostic findings in strabismus are very subtle and even you may not have noticed things that are important to the Pediatric Ophthalmologist in making a diagnosis and giving you your medical and surgical options.

Good Luck

General information on dry eyes/tears dysfunction syndrome

Dec 11, 2009 - 36 comments

General Information on Dry Eyes-Now known as Tears Dysfunction Syndrome.

June 2014 UPDATE: A new product "OcuSOFT Lid Scrubs PLUS has worked extremely well for the condition called blepharitis (oil and debris and irritation along margin of eyelid) associated with dry eyes. The PLUS product works much better than the regular OcuSOFT Lid Scrub plus the PLUS product is left on the lids and does not have to be dried off.   RESTASIS continues to be the medication of choice for moderate or severe dry eyes.

September 2013 UPDATE:  Restasis has become the #1 most prescribed eye drop in the USA and most other developed countries. It is the preferred treatment for moderate or severe dry eyes. Improvement can occur for up to 1 year.  It works for the eye with no tears or the eye that waters all the time. If often stings or burns when first starting and many ophthalmologists use a mild steroid eye drop for a couple of weeks to reduce swelling. Restasis is not an artificial tear but is cyclosporin. Over 4-6 months Restasis reduces inflammation on the surface of the eye and improves the quality and quantity of the tear  (which has a protein, a fat (lipid) and a watery (aqueous) component.

Also recent research has documented the effect of omega 3 fatty acids taken orally 2 or 3/day.  This includes high quality enteric coated fish oil or other ocean based Omega 3 such as made from krill or calamari. Omega 3 helps dry skin, dry mouth and dry hair.  This also often takes 3-6 months to get maximum benefit and needs to be continued. Important to understand NO IMPROVEMENT MAY OCCUR FOR 4-6 MONTHS.

Both Restasis and Omega 3 are normally taken for life.  A recent study stating fish oil increased risk of prostate cancer in men is wrong.  Omega 3 does NOT increase the risk of prostate cancer *See Missouri Medicine medical journal July/August 2013.


a Schirmer test of zero indicates that severe dry eyes. I'm assuming from your posting that you have tried both preserved and unpreserved artifical tears, gels or lubricating ointments at bedtime, environmental modification, etc. Don't discount eye drops. There are over a 100 different brands of artificial tears and they can't all be lumped together. Sometimes one will find the perfect drop. Because the problem is so prevalent the pharmaceutical compies are coming out with new products all the time. Some of the newest are Systane preserved and unpreserved drops and Optive drops. Eye drops for dryness are classified as preserved drops (individual vials that must be used within 24 hrs), preserved drops, gels and ointments. The preserved 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 tears won’t last all night.   There is also an over the counter spray for dry eyes called “Tears Again”.  Tears may need to be used as often as 6 times/day.

If you took Restasis you have used the best prescription medication. A "trial" of Restasis is a minimum of 6 months of therapy using one drop in each eye twice/day. Because of the way Restasis works, it takes four months to "start working". I have found that many patients use it for a few weeks then conclude it won't help. The medication often stings when therapy is begun--it usually gets better by week three or your Ophthalmologist (EyeMD) can prescribe a mild steroid drop for a couple of weeks. Improvement often continues for up to 12 months.

If you have tried tear duct plugs you should have had all for tear duct openings (puncta) plugged with a permanent plus (not a disolving one). Usually just the lower lids are done with mild dry eyes. If your problem is as bad as you say, you and your ophthalmologist should discuss permanent closure of some or all four of the tear duct openings with cautery.

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/

Additional things that can help include a diet rich in fatty fish (eg salmon, sardines, etc). Fish oil taken by mouth usually 2 to 4/day has been show to help some patients. 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.

Ask your ophthalmologist (Eye MD) about Lacriserts. These were unavailable for several years and are now on the market by Aton Pharma. They are very tiny pellets of hydroxypropyl cellulose that are placed between the eye lid and the eye and slowly dissolve over 24 hours coating the eye with a moisturizing coat.  They are a prescription medication.

In dry eyes associated with corneal damage, moisture retaining goggles are used for sleeping. Be absolutely certain you do not sleep under a fan, heating outlet or situation where air moves over your face during sleep. Make certain you home is humidified in the winter, put a humidity gage in the bedroom. If you cannot maintain a 50-60% humidity put a room humidifier in the bedroom. Run the A/C or heater of your car through the vents on your feet not in your face. Long car or plane trips put your tears in every couple of hours.

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. Many medications eg antihistamines can make dry eye worse. You might review your medications with your ophthalmologist.

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.

Keep digging and moving forward. I suspect you have not exhausted all the ways you can be helped.