Search for tag: "Vision"
A majority of children will not develop 20/20 vision until they are four to six years old. During those first few years, what should parents do to make sure their kids maintain healthy vision?…
December 05, 2022
Parents often ask me when I will be able to tell if their baby can see normally. That's hard. But vision screening is something that we do at well-child visits if your child does not already see an eye doctor. Today, I'll discuss the basics of vision screening in kids.
For children under age 3, any vision concerns need to be referred to a pediatric ophthalmologist, who is a medical doctor who treats eye issues. Some optometrists, who are doctors of optometry, or ODs, will see kids as young as 6 months old, but not usually.
Now, as pediatricians, we look at the eyes of kids starting at birth. We look to see if they have congenital cataracts, if their red reflexes are good. You know, when you take a picture of your kid and they have really bright red pupils, that's actually a good thing. We'll see if they have lazy eye or any other eye concern for which we need to have them see a specialist. But it's hard to check in the office to see if they need glasses at that age.
The American Academy of Pediatrics last updated their vision screening guidelines in 2021. We start doing vision exams at well-child visits starting at the age of 3. I usually tell kids at their 2.5-year well-child visit that when they come back to see me at 3, we'll have them play a picture game with my medical assistants.
It's actually the screening for visual acuity, which is to evaluate to see if they need to see an eye doctor for possible glasses. But a picture game sounds a whole lot more fun.
Kids up until age 4 normally have 20/40 vision, and by age 5, they will have 20/30 vision. After that, their vision should be 20/25 or better. 20/20 is what most people know as normal vision, and that's what they should ideally have by age 6.
Often, the schools will want a child's vision screened before kindergarten. They will also do vision screening in the schools periodically. The parents will be notified if their child fails their vision screen, and we can repeat the vision exam here to make sure of the results, especially if the screener at school did not document on the letter what the child's visual acuity was.
Then we can help the family find an optometrist that can do a more in-depth vision evaluation and see what kind of glasses the child may need.
The forms that the schools send home usually require a signature from an actual optometrist to prove that the child saw an eye doctor. As pediatricians, we are not qualified to complete those forms and they will be returned to the parents if we fill them out. So if your child gets one of those forms, they do need to see an actual eye doctor.
We recommend that a child has their vision screened at least once a year. That's why we do them at the well-child visits, which also happen once a year.
If your child wears glasses or contacts, the optometrist will let them know how often they need to be seen. Normally, it's still every year to make sure their prescription has not changed.
If you have any questions about your child's vision, talk to your child's pediatrician and we will evaluate what we can and let you know if your child needs to see an optometrist or an ophthalmologist for further testing.
A majority of children will not develop 20/20 vision until they are four to six years old. During those first few years, what should parents do to make sure their kids maintain healthy vision? Learn the vision screening expectations during the first years of your child’s life, how to navigate school vision screening requirements, and when your child may need to see an optometrist.
Resistance bands are a great exercise and physical therapy tool—but can sometimes be dangerous. Emergency physician Dr. Troy Madsen talks about the types of eye injuries caused by exercise…
April 06, 2021
Interviewer: Are you working out from home with exercise bands? Well, you might want to watch out for this injury.
Dr. Troy Madsen is an Emergency Room physician at University of Utah Health. And a lot of us are trying to get in some exercise at home, and we might reach for those exercise bands. But, Dr. Madsen, I understand that there could be some risk working out with those exercise bands. Tell me more about that.
Dr. Madsen: You know, Scot, I have used exercise bands, and this is a risk I've never really considered, but apparently there is an increase in risk and injury to the eye that has been something that's been noted since the pandemic started. So what we're seeing, I think, more and more people are not going to the gym, they're working out from home, and a great tool is a resistance band. If you've ever used this, it's like a giant elastic band. You know, these things are huge. You put it around your foot, and then maybe you're leaning back or doing something with your leg, all kinds of different things, stretching, strengthening.
Well, at the University of Miami, they actually published their experience with seeing multiple patients come to the Emergency Department with injuries to their eyes from these resistance bands. So the title of this article is "Ocular Trauma Secondary to Exercise Resistance Bands During the COVID-19 Pandemic," published in the "American Journal of Emergency Medicine."
And you can imagine how this can happen. I don't know if this has ever happened to you, but let's say you wrap it around your foot, and you're stretching your leg out, and that thing is really tight. And then, maybe you've got socks on or something, and it slips off your foot and flips back and hits you in the eye.
Interviewer: Oh. Ow. Oh.
Dr. Madsen: Yeah, sounds miserable. Sounds absolutely miserable.
So they reported their experience in the "American Journal of Emergency Medicine," and they talked about 11 patients they had seen, and these were not minor injuries to the eye. So they said 11 patients, 14 eyes, so that means several of these patients had both eyes injured. Eighty-two percent of these patients had a hyphema.
So a hyphema is a pretty big deal. That's where you get blood behind the cornea. And, you know, if you ever look in the mirror, you see the cornea, you see your iris, the colored part of your eye. The cornea is the clear part over the top of that. And if you ever see blood there, it just looks like just this red line that's filling up behind there, that's a pretty big deal. That's a serious injury.
And then, vitreous hemorrhage in 36% of these patients. That's blood back behind the iris, back in kind of the main part of the eye. That can really affect your vision. Potentially, if it causes enough damage, potentially have long-term effects. Same thing with a hyphema if it's not treated.
So these are not minor injuries, but they saw a number of these, and just given the number they've seen, they reported on it in the "American Journal of Emergency Medicine" to make people aware that things are happening with resistance bands.
Interviewer: All right. So not happening to, necessarily, a large number of people that we know of, but is in the realm of possibility of happening apparently.
Dr. Madsen: Exactly. And I think the reason they published this and their conclusion was, if you're using a resistance band, wear glasses or consider wearing goggles. I mean, it may seem like overkill. It is something that emergency departments are seeing. This is one emergency department's experience. I'm sure it's happening elsewhere. I have to be honest. I have not seen this in the ER yet, but if we talk to some of our ophthalmologists, my guess is that they probably have. So it's out there, it's happening. You know, takeaway, be aware of it and consider wearing some glasses or goggles if you're using a resistance band.
Interviewer: Yeah, or consider just making sure that you're looking at how you're using it, and "If it was to slip right now, would it slip back and snap me in the eye?" And is there an adjustment you can do in your form that would, you know, prevent that from happening?
Dr. Madsen: Yeah, exactly.
Types of eye injuries caused by exercise bands and how to protect yourself.
As your loved ones get older, there’s a good chance they will begin losing their vision, and in turn, their ability to drive safely degrades. But taking away the car keys from a loved one can…
October 09, 2018
Announcer: Need reliable health and wellness information? Don't listen to the guy in the cube next to you. Get it from a trusted source, straight from the doctor's mouth. Here's this week's listener question on The Scope.
Interviewer: All right, today's patient question is from a gentleman named Ken. He says that his dad is starting to lose his eyesight, and they're concerned that his driving isn't as good as it needs to be.
So how do you have that conversation to take away the keys? It can be a scary thing to do. And to help answer this question we have Lisa Ord. She's a licensed clinical social worker. She also has a PhD in social work and is the Patient Support Program Director at the Moran Eye Center.
So how do you have that conversation?
Lisa: Having that conversation with one of your parents is probably one of the toughest conversations you're going to have, especially here in the West where we rely so much on driving and how much of our individual freedom is attached to be able to get in the car and go where you want when you want to. But the problem is that when someone isn't seeing as well as they need to be seeing, it gets frightening.
And it's not only frightening for them, but it's frightening for anybody else that's on the road or walking on the side of the road. So being able to have the conversation with your parents is very important. And to start with saying, "You know, dad, you've just had your eye checkup, and I see that it's not getting better. They can't correct it. Have you thought about other ways of getting to where you need to go other than driving yourself?"
Interviewer: And then you just pause and wait for that answer?
Lisa: And you pause and wait. Exactly. And it may be met with anger and just being able to be with that and say, "I know that this is a tough conversation, not something you even want to talk to me about." But the tougher conversation is the conversation after you've hit somebody because you didn't see them.
Interviewer: So this is a conversation that if you feel that somebody that you love is not seeing well, you need to have a . . . you outlaid a very direct approach. Are there other ways, if you don't think the direct approach is going to work with your particular loved one?
Lisa: I've had patients use different approaches. One patient said, excuse me, one daughter of one of my patients said that she finally said, "My children will not ride with you in the car. We either need to have someone else drive, or you're not going to be able to take them where you want to take them." So it was kind of like putting it in terms of, "I don't feel safe enough to be in the car with you. I don't feel safe enough for you to take my children in the car with you."
Interviewer: And that really kind of brought the reality to bear?
Lisa: To bear, yeah.
Interviewer: Is there somebody else you could involve, like a health care professional perhaps, because maybe they would be more willing to take it from a third party?
Lisa: I have a lot of patients that say, "But my license doesn't expire for another two years, so I don't have to worry about it." And that's not the case. You're still going to be very much liable whether your license is expired or not. If you're not safe to be driving, your eye care professional will have to fill out a medical form stating what your visual acuity is, and your visual field if you are not being able to be corrected to 20/40 or better. So that is something that they're going to have to do. Having the health provider have that conversation with your parent is sometimes easier because it does kind of put that onus on the healthcare professional.
The other thing is that if you really can't have the conversation, you really are concerned about your parents' driving or anyone's driving, you can make a report to the DMV, and they will take it upon themselves to have that person do a driving test.
Interviewer: Okay. All right. Probably not the way that most people would want to handle it. But I guess as a last resort . . .
Lisa: As a last resort. And I have had some family members who say their parents are so adamant that they're, you know, having extra keys made every time the keys are taken away from them, things like this. And so you're left with no other resort, except for to call in the people whose ultimate responsibility is to take away the license, and that is the driver's license division.
Interviewer: Ultimately, though, if somebody is faced with a vision impairment that could endanger them or others while driving, whatever you do, you would recommend something has to be done.
Interviewer: Don't leave it to chance.
Lisa: Don't leave it to chance. Not a good plan.
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Vision loss impacts every aspect of a person’s life. Facing these challenges alone can lead to a lot of adverse psychological effects. Lisa Ord, from the patient support program at Moran Eye…
September 20, 2018
Announcer: Health information from experts supported by research from University of Utah Health. This is thescoperadio.com.
Interviewer: When first faced with the reality of vision loss, life can seem overwhelming. Denial, anger, fear, grief, hurt, rejection, abandonment, those are just some of the common psychological reactions that somebody could have when faced with the reality of life without or just even with limited sight. And without proper guidance, in many cases there's a great potential for isolation, depression, and dependence. That's why it is important to intervene early if somebody's losing their vision to help avoid some of these things happening.
Lisa Ord's a licensed clinical social worker. She also has a PhD in social work and is the Patient Support Program Director at the Moran Eye Center. It sounds like that vision loss is a lot more than just a physical issue, which a lot of people obviously know. There's a lot of psychological and mental stuff going on that we might not be aware of.
Dr. Ord: It really does affect every aspect of your life. It affects how you see yourself. It affects your roles with other people. You have to grieve it.
Interviewer: Yeah. And it affects your family. It affects the individual. So I'm somebody that has a loved one that's going through vision loss. And now, because of this first little bit here, I realize that there's a lot more going on than just the physical loss of sight. So how could I better support a loved one going through this?
Dr. Ord: I think the first thing you need to do is acknowledge with them that, you know, Mom, Dad, I know that you don't see as well as you used to, and I know that that can also affect other things that you've got going on in your life, and I want to know how I can best help you if you do want help, or help you to learn how to do what you want to do without as much sight as you've had.
Interviewer: Got you. So just open that dialogue.
Dr. Ord: Open the dialogue.
Interviewer: Do you find that most times that people are pretty responsive with that, or are they like my parents? They'd be like, "Oh, I'm fine."
Dr. Ord: It's the generation. Isn't it? You know, some are, some aren't really. But even if they, you know, "I'm fine," to you, they've heard you, and they know that you're aware and that you're there and that you want to help.
Interviewer: How much should you push the conversation at that point?
Dr. Ord: I would never push too hard. I have patients who say, you know, "My family, they won't leave me alone."
Interviewer: Oh, yeah? And that's all they want, is just leave me alone.
Dr. Ord: And there's others, they're just like, you know, "I really need some help, and there's nowhere to be found." So there's a happy medium.
Interviewer: That's right. Okay. So do you have any tips on how to approach the conversation? I think you gave us one already, just open up with, "I understand that this can be an issue that can lead to other issues. How are you doing? How are you feeling? Can I help you?" What other tips?
Dr. Ord: Exactly. I think, you know, acknowledging that maybe what you've been seeing in the anxiety of, "Am I going totally blind, or am I just losing some of my vision? What's going to happen? How am I going to manage?" Those kind of conversations I think are super important to have and just opening up to them and saying, you know, "I've been reading. I've heard that things can be very difficult. And how are you doing? How are you feeling about this?" Allow them and encourage them to continue doing the things that they want to do. And there is a way of doing everything if you know how to do it without sight. Sometimes they just need some tips and tricks on how to do something without being able to see it as well as they have in the past.
Interviewer: So tell me about some of the programs that you have at the Moran Eye Center.
Dr. Ord: So we have support groups. It's very important they get a lot from being able to talk with other people going through very similar things that the individual is going through at the time. We also have psychotherapy because it is a loss. You need to grieve it. There's a lot of anxiety. There's a lot of depression, so we do counseling. We also do skills, some basic vision loss skills and how to do things. We have an orientation to vision loss once a month on a Saturday that we talk about magnification, lighting, contrast, using your other senses, giving some tips on how to do things in a different way.
Interviewer: Yeah, my dad had macular degeneration, and I didn't really realize any of these things existed, and it would have been great to have had access to that sort of thing. We're very lucky here in Salt Lake City to have access to, you know, those resources at Moran Eye Center. Somebody who's not in Salt Lake City, how can they find resources?
Dr. Ord: There is a great website. It's the American Foundation for the Blind or afb.org, and there is a directory that you can search by state to find services in your area. Every state will have some kind of services for the visually impaired and blind. Sometimes it goes through the Office of Rehabilitation, sometimes it goes through the Office of Education, but every state will have some services.
Interviewer: And it sounds like people that use these resources find them very beneficial.
Dr. Ord: Oh, very beneficial.
Interviewer: It might be difficult to get somebody there at first but well worth it.
Dr. Ord: Absolutely. If you're losing your vision, it's okay to really have some strong emotions about it. It's okay. Then it comes to a point where it's like, "Okay, what am I going to do about it?" So then you take the next steps in learning how to live life fully, even with your vision loss.
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Sometimes when people lose their vision, they can begin to have hallucinations. It’s called Charles Bonet Syndrome (CBS) and is more common than you think. It may sound scary but it’s…
August 15, 2018
Announcer: Health information from experts supported by research. From University of Utah Health, this is thescoperadio.com.
Interviewer: Sometimes when people lose their vision, they start having hallucinations. It's a condition called Charles Bonnet Syndrome. CBS might not be well-known or documented, but it is extremely common and harmless. Lisa Ord is a licensed clinical social worker. She also has a Ph.D. in social work, and is the Patient Support Program Director at the Moran Eye Center.
So, first of all, Lisa, it's fascinating that many people might actually have this condition but don't say anything about it because they're afraid they'll be diagnosed with mental illness or dementia. So tell me more about that part of it first.
Lisa: Well, I think it's really important for people to realize that they're not going crazy. So the big difference between Charles Bonnet Syndrome and say psychosis caused from mental illness or dementia is the level of insight for number one. People realize that what they're seeing isn't really there. It can't be there. If they don't realize that when it is explained to them that this is caused because your brain hates to have a void, it's used to a lot of visual stimulation. And so it's creating this for you, then it's like, "Oh, okay." Whereas somebody with psychosis or dementia, you can't get them off of that idea that it's real.
Interviewer: And when a lot of people that have this condition are in a support group and they hear that their loss of eyesight also might be related to these hallucinations, they sigh a sigh of relief.
Lisa: Yes. Yes, because here they've kept it a secret. They haven't wanted to tell their family. They haven't wanted to tell their healthcare provider for fear that they're going to be carted off and not able to live alone anymore. A lot of our patients do live alone and quite independently.
Interviewer: Yeah. It's fascinating. So if you start losing your vision, your brain wants to see so badly that it just starts. Tell me more about how it's filling that void.
Lisa: Well, it's interesting to me. We don't know a lot about it, but what we do know is that through some fMRI studies that it's the same visual pathways that are engaged when somebody is seeing a hallucination from the Charles Bonnet Syndrome as when they're actually seeing the object. But when they're just imagining the object or visualizing the object, it doesn't engage those same pathways. So we do know that it is as if we are seeing that thing that we're seeing, and people see a variety of different kinds of things.
Interviewer: Yeah. Do you have any examples?
Lisa: Yeah. So I have a patient who saw the Grand Canyon opening up in front of her. Rather disconcerting. She knew it wasn't there, but still it was a little bit unnerving.
Interviewer: Like the ground opening up . . .
Lisa: The ground opening up.
Interviewer: . . . as if it's a Grand Canyon. Wow.
Lisa: Yes. I've had people that saw flowers or patterns. I've had a gentleman who saw a train and just passing in front of his eyes. A lot of people actually see other people, and these are not necessarily people they recognize.
Lisa: In fact, most the time they don't recognize them.
Interviewer: Can those hallucinations be dangerous?
Lisa: No. They're not dangerous at all.
Interviewer: Not even the person that thinks they see the train? I guess that's better than not seeing a train. Of course, they can't . . .
Lisa: I guess it depends what do you do with it, right?
Interviewer: Yeah. If they're losing their vision, then they're not seeing it. Yeah. Right.
Lisa: Right. But there are lots of things you can do to get the visions to go away.
Interviewer: So is there a point in vision loss where it starts to happen? Is there a threshold where if it's going to happen, it might start happening at that point?
Lisa: Well, what we see is usually people who have more of a severe vision loss also maybe a field. A visual field defect where they have a blind part of their vision and that's actually where they're going to see the hallucination is in that blind spot.
Interviewer: And do some people still see some real things and then that's also the hallucinations are on top of that as well?
Lisa: Yes. Hallucinations can be almost superimposed on top of that as well. Yes.
Interviewer: Like virtual reality in a way.
Lisa: Yes. Exactly.
Interviewer: Yeah. So is it primarily older people that get the condition, or is it just we tend to think of it in older people because they're more likely to have lost their vision?
Lisa: Exactly. It can happen to anyone who has had vision before. Your brain has to know how to see. It has to be used to that visual stimulus. But like you said, most blinding conditions are happening in the elderly or they're age-related conditions. So that's the population that we're more likely to see them in. It can happen in children.
Interviewer: What are some of the specific conditions where it starts happening? So macular . . .
Lisa: Macular degeneration . . .
Interviewer: . . . could be one of them. Yeah.
Lisa: The big one. Glaucoma, diabetic retinopathy. There's many different kinds of conditions that cause blindness. It doesn't really matter. It's not really tied to one condition or another.
Interviewer: Got you. Is it curable?
Lisa: It is not necessarily curable. There are things you can do to get the hallucination to stop. Sometimes they just stop on their own.
Interviewer: Okay. So just because it happens once doesn't mean it's going to continually happen?
Lisa: I have some patients who have it continually quite a bit. Other patients it's like, "Yeah, that's happened to me once or twice."
Interviewer: Okay. All right. And what are some of the strategies for managing it?
Lisa: So one thing that you want to do is change the lighting in your room. So if you are in a dim room, turn on the lights, open the drapes. Another thing that you can do is blink rapidly, change your location, do something else, something that engages your brain, whether it's a hobby or talking to someone else, giving your brain another kind of stimulation.
Interviewer: If somebody believes if they or a loved one has Charles Bonnet Syndrome, what should they do at that point? Should they go see an eye doctor? Do you go see somebody else?
Lisa: Well, they can go see an eye doctor. They can see their primary care, but not being afraid to mention that, "I have vision loss and I am also seeing these interesting or not so interesting visions." That doesn't necessarily mean you're crazy. And providers, even though they may have learned about this once in medical school, they don't think to ask people. So if you are a provider that works with elderly people, remembering if they have vision loss to ask, "Do you see things that aren't there?"
Interviewer: Yeah. And frame it.
Lisa: And frame it.
Interviewer: And frame it that this is . . . yeah.
Lisa: We have patients who see things that aren't there and they know that. Is that happening to you?
Interviewer: What about if you have somebody that has lost vision in your life. Is this a conversation you should have with them, just to make it safe for them to talk about it?
Lisa: Yes. I think just opening up that conversation saying, "I heard about this the other day, and I was wondering if that's ever happened to you."
Lisa: It's totally normal.
Interviewer: And I bet a conversation like that could take just a load of stress off of somebody that thinks that they're going crazy, right?
Interviewer: Yeah. What do you think that the ultimate takeaway that you would like somebody to have as a result of the conversation we had about Charles Bonnet Syndrome?
Lisa: I think the ultimate takeaway is that it is not as rare as we once thought. We find that about one in four of our patients with vision loss have experienced this. So talk to somebody about it. You're not going crazy.
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A broken blood vessel in the eye can look nasty. But is it worth a trip to the ER? Emergency room physician Dr. Troy Madsen talks about when you should seek emergency help and when you can just see…
January 26, 2021
Interviewer: It's another edition of ER or Not with Dr. Troy Madsen. Go ahead and play along and see if you know the answer to today's situation. You have a broken blood vessel in the eye and I'm talking about like, you know, sometimes you'll see somebody, they have an eye and there's just like a lot of blood in it, right? Is that a reason to go to the ER or not?
Dr. Madsen: So this is probably not a reason to go to the ER. So if you wake up . . .
Interviewer: But they look nasty.
Dr. Madsen: They look nasty and they look awful. It's kind of like if you get like a scratch on your face and you have a Band-Aid, everyone is going to ask you about. If you have a Band-Aid on your finger, no one ever asks you about it. But if it's in your eye . . .
Interviewer: All about location, yeah.
Dr. Madsen: Yeah. If you get a little bruise on your arm, no one's asking you. If it's a bruise in your eye, everyone is going to mention it. So it's something that draws a lot of attention, but it's not something you really need to go to the ER for.Broken Blood Vessel Behind Cornea
Now, the one exception to this might be if you get hit in the eye and there's actually blood behind the cornea, so behind that clear part of the eye in front of the iris, the colored part of the eye, and you see a line there that looks really dark, that's more concerning. So that's not behind the white part of the eye, that's behind the cornea and that's called a hyphema. So the reason that's concerning, that can cause issues with high pressure in the eye and cause staining of the eye, all sorts of things that can be problems, that would be a reason to go to the ER.
But here we're talking more about you wake up in the morning, you've got blood in the white party of your eye in the sclera. And you say, "Wow, this looks awful," probably you don't have to go to the ER. You could probably just go see an ophthalmologist or an optometrist.
Interviewer: All right. And what causes that, do you know?
Dr. Madsen: You know, most cases I see, it's some kind of trauma. Someone got poked in the eye or they hit something or maybe they were just rubbing their eye too hard and it just caused a little blood vessel to burst. You got to figure those vessels are pretty small, probably doesn't take a whole lot of pressure or trauma to make one of those burst open and that's usually what causes it.
Interviewer: All right. So just to make sure I'm clear, if it's in the white of the eye just go see my own eye doctor. If it's behind the colored part of the eye like a red line or something, that's when I should go to the ER.
Dr. Madsen: Exactly.
You've noticed a broken blood vessel in your eye. Should you go see a doctor?
The occasional “knuckle rub” to an itching eye can feel relieving, especially as allergy season starts. But according to Dr. Mark Mifflin, professor of ophthalmology, chronic eye itching…
October 12, 2018
Dr. Miller: Rubbing your eyes might feel good, but it is really bad. Is that true? We're going to talk about that next on Scope Radio.
Hi, I'm here with Dr. Mark Mifflin. He's a professor of ophthalmology at the University of Utah. Mark, is rubbing your eyes too much a problem? Can that lead to some bad outcomes?
Dr. Mifflin: Yes, actually, it wouldn't be necessarily intuitive that rubbing one's eyes could result in actual damage to the eye, but it's fairly common.
Dr. Miller: Now everybody at some time has got to be rubbing their eyes. So are we talking about a small number of people?
Dr. Mifflin: Well, we actually see a category of disease, perhaps two, that are related to chronic eye rubbing. Certainly, short term eye rubbing is probably not going to cause a problem except for maybe a very few patients who may have some kind of severe problem underlying their eye condition. But chronic eye rubbing can result in the weakening of the cornea and distortion of the cornea called keratoconus.
And it's often associated with people with very bad allergic conjunctivitis or itchy eyes and, unfortunately, some of these people are so itchy that they nothing feels better that . . . I call it the knuckle rub to the eye. Unfortunately, over time, that can actually weaken and distort the eye.
Another thing that can be associated with chronic eye rubbing is actually laxity of the eyelid. The eyelid can, over time, lose its elasticity and that's a less serious problem, but still not something that we want to happen.
Dr. Miller: So if somebody was rubbing their eyes because they have severe allergies in the spring or even year-round, how do they end up at your doorstep? Is it that their vision is blurred at some point?
Dr. Mifflin: Yes, typically, most of the patients who we feel that actually there is an association between chronic eye rubbing and disease fall into the diagnosis of the condition called keratoconus, which is a structural abnormality of the cornea causing poor vision due to an abnormal shape to the surface of the eye. The shape causes irregular astigmatism, which often cannot be corrected by glasses or even contact lenses in its severe stages.
One really important is that this disease may run in families and, typically, may start even in childhood. So certainly, parents should be advised to try to seek treatment for their young children who may have severe allergic disease and in the case of eyes, typically allergy eye drops are very effective in eliminating itch. And behavior modification just through teaching can help children not rub their eyes.
Dr. Miller: Now, how do you know if you're rubbing your eyes too hard?
Dr. Mifflin: I tell my patients that the amount of pressure needed to wash one's face with a washcloth gently or dry with a towel is the appropriate amount of pressure to put on one's eye. Anything more than that is probably unhealthy for the eye.
Dr. Miller: So if you're rubbing to the point where you're seeing stars, then it's a bad thing?
Dr. Mifflin: It is possible to induce the sensation of light or the perception of light without actually seeing light. And this can occur with the eyelid closed and these little sparks of light are called photopsia and certainly, when one rubs their eye hard enough to induce photopsia, that is not a good thing.
Dr. Miller: And if you do that repetitively, you might end up in the ophthalmologist's office.
Dr. Mifflin: I would say that there is a good chance that if you do it over a period of years, you could end up with even worse than that.
Chronic eye itching can lead to serious, irreparable damage to your eyes.
When you think of corrective vision surgery, LASIK may be the first procedure that comes to mind, but did you realize there are other options available that might be better for you? PRK is an older,…
March 28, 2016
Interviewer: When you think of vision correction surgery, most people think of Lasik. It's not the only option. We'll discuss what the other treatments might be next on The Scope.
Announcer: Medical news and research from University of Utah physicians and specialists you can use for a happier and healthier life. You're listening to The Scope.
Interviewer: We are in the office of Dr. Amy Lin today. She's an ophthalmologist at the Moran Eye Center at the University of Utah. Dr. Lin, first of all, tell me why someone would even need to go get Lasik.
Dr. Lin: People get Lasik to get out of their glasses or contact lenses. They want to correct their nearsightedness or their farsightedness or their astigmatism. That's why someone would want to have Lasik.
Interviewer: That's not the only option, I'm hearing. There are other surgery options besides Lasik.
Dr. Lin: That's correct. The most common alternative to Lasik is something called PRK. PRK was actually the precursor to Lasik, but we still do a lot of PRK nowadays because there are certain advantages with PRK. And it does the same thing as Lasik, corrects nearsightedness and farsightedness and astigmatism. Instead of having a flap in the cornea like there is with Lasik. With PRK, there is no flap in the cornea, but your eye has to heal over naturally.
Interviewer: When a patient comes to the office and they ask you for suggestions of what treatments and what surgery they should do, how do you decide Lasik is better for you or PRK?
Dr. Lin: We do a whole variety of measurements in the office. We measure the steepness and the shape of the cornea. We measure the thickness. We measure the prescription in the eyes. And based off of that data, we decide is the cornea thick enough for Lasik and PRK because you do need a thicker cornea for Lasik. Is the prescription too high for Lasik and maybe still ok for PRK? That's kind of one objective measure that we have for choosing one or the other.
There are other parameters that we look at. We actually look at the patient and if they have a lot of dryness in their eyes, like they can't wear the contact lenses for a long time because their eyes become too dry, with Lasik, we know that you get a lot of dry eye afterwards than with PRK. If you have dry eye existing, it may be a better option to go with PRK rather than Lasik so you don't worsen your dry eye.
Interviewer: When your doctor tells you that they recommend PRK as your treatment, does that mean that you are not a candidate for Lasik? Can you not do Lasik if you are recommended PRK?
Dr. Lin: Usually, people are either candidates for both or candidates for just PRK. If a doctor recommends to you that they recommend PRK, usually, it means there's something that usually bothers them in Lasik and they think it might be too risky to do Lasik, but it would be safe to do PRK.
Interviewer: Now, are the outcomes of both of the surgeries the same?
Dr. Lin: Yes, the outcomes are the same. When they do the studies that compare PRK versus Lasik, the visual outcomes are the same. PRK takes a lot longer to heal whereas Lasik is a lot faster. Lasik people are saying well after a day or so. With PRK, it takes several weeks. That's not to say that you're blind for several weeks. It's just not to be quite as crisp and clear for several weeks, but the vision does get there. Interviewer: With gradual outcome.
Dr. Lin: Exactly.
Interviewer: With Lasik, from what I understand, there is a laser involved that corrects your eye vision for you. Tell me about PRK. Is that the same thing? Is there a laser involved or is it some totally different procedure?
Dr. Lin: Both Lasik and PRK have a laser involved. With Lasik, there are actually two lasers involved. There is one laser that cuts a flap and the cornea and then, there is a second laser that corrects for the vision. And with PRK, we just use the laser that corrects for the vision. After the laser procedure, with PRK, a bandage contact lens is actually put on the eye and that contact lens is kept in the eye for several days so that your eye can heal. Whereas with Lasik, there isn't any extra material put on your eye. Your eye kind of . . . it's fast and your eye is almost kind of healed at that point. There's really nothing to cover up.
Interviewer: Is there one that you would prefer over the other, in terms of their kind of better outcome long-term.
Dr. Lin: PRK could be a little bit safer and the reason is that with Lasik, there's kind of a long life risk of having additional damage to your eye if your eye gets hit really hard. We're talking hard injury like a car accident, baseball to the eye, a big fall, something like that because the cornea isn't that 100% strength. There could be additional injuries to the eye with whatever injury hits you in the eye, but if you have PRK and you get hit in your eye later on, any eye injury you would have wouldn't be any different than getting hit in your eye right now.
Interviewer: PRK is not a surgery that a patient could come into your office and say, "I want this surgery." It's something that you need to evaluate and it's a doctor-prescribed treatment?
Dr. Lin: Exactly. PRK is an elective surgery, but we still need to see if you are a candidate for it. But some people are not candidates for Lasik and some people are not candidates for Lasik or PRK. I think they're both great procedures and the only way to for you to determine that is to see a doctor, get all the testing to see if you're a candidate.
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Even though hundreds of thousands of LASIK procedures are performed safely every year, it can still be scary. Dr. Mark Mifflin at the Moran Eye Center finds that when patients know what’s going…
February 16, 2016
Announcer: Access to our experts with in-depth information about the biggest health issues facing you today. The Specialists with Dr. Tom Miller is on The Scope.
Dr. Miller: Hi, I'm Dr. Miller and I'm here with Dr. Mark Mifflin. He's the Professor of Ophthalmology and his practice includes refractive surgery, otherwise known as LASIK to many.
Now if we go to the operative day where they're going to have the procedure, is that a fairly involves surgery or is it fairly straightforward, done under local anesthetic, or do they have to be under general anesthesia? Just describe that procedure a little bit more.
Dr. Mifflin: Yeah, the actual procedure itself is outpatient and pretty user-friendly. I like to think of it that way. Amazingly, most modern eye surgery, at least on the anterior part of the eye, and this would include laser vision correction surgery, is done with what's called topical anesthesia which means we just actually numb the eye with several eye drops, maybe three or four sets of numbing drops. Amazingly, that can result in a pain-free surgery. And typically, for vision correction surgery there's no sedation, no IV, and it's done in kind of a clean setting in a laser room but the person doesn't have to change into a hospital gown or anything like that.
Dr. Miller: So patients coming in for the surgery might be anxious on the operative day. Some people are very concerned about having their eye touched, and I can understand that. That gives people a sense of squeamishness. How do you calm patients who are coming in for surgery? Obviously they're going to be awake. You mentioned that you're going to use a topical anesthetic so they're going to know pretty much what's going on during the surgery, and I would suspect a number of people would be anxious. How do you calm them and how do you get them through the surgery so that you have a really good outcome?
Dr. Mifflin: The day of surgery is actually a culmination of a long process of teaching the patient and kind of letting them know what the whole experience is going to be like, not only preoperatively, but during the surgery itself and then also the recovery phase. It's actually very easy for most people to go through. We literally handhold. We have a staff of about three or four people in the laser room. We have nurses and technicians who have been doing this for decades, some of them. So anything from gentle coaching by the surgeon in which there is constant verbal interaction. Some people even call it a vocal local, meaning kind of calming the patient by talking to the patient and coaching them and kind of telling them what to expect.
Dr. Miller: Vocal local. That's good. So I'm assuming that they've got to be completely still while that laser is performing the procedure, doing the changes, sculpting on the lens.
Dr. Mifflin: Interestingly and that . . . you're absolutely right. It's a great source of anxiety for patients. Not only, number one, we have really strong reflexes to keep things away from our eyes. That's just ingrained in us. The concept of somebody doing something to your eye is unpleasant, but again, through the educational process and also a very stepwise process where we kind of ease in to the surgery, it's amazing that pretty much anybody can tolerate it.
Part of that process again is the fact that it is pain-free and the laser technology actually tracks the eye just like a weapons technology laser or something would track a target. That's how the laser technology works, so even though the patient is a little bit worried about not looking in the right place . . .
Dr. Miller: The laser is sophisticated enough to be able to do that automatically.
Dr. Mifflin: That's absolutely right. The patient looks at a target. The surgeon is aligning the laser, and then the laser has a camera and/or lasers in it that is tracking the pupil. Between those things, I've never seen one of these laser tracker fail. It's very, very accurate. So if the patient should look away more than about a half a millimeter the laser automatically quits firing.
The actual sculpting or laser ablation typically would last between 5 and 20 seconds per eye, so it's very quick. In LASIK surgery the initial stage of the surgery is cutting a flap and that takes about maybe 30 seconds, so the actual time under the laser where they are really kind of critical things going on is really usually less than a minute per eye.
Dr. Miller: Do you usually do one eye per session or do you do them both?
Dr. Mifflin: Very early, we recognized that this was extremely reliable technology and by doing one eye at a time it was mostly just inconveniencing the patient. Rarely, we still see patients that are a little bit uncomfortable with the thought of doing both eyes and we offer that option. Most people are afraid to have this surgery, but by the time we have finished educating them and get them to the day of surgery they are very comfortable.
The other fear that patients have is that they are able to do something to cause a bad outcome, and that is actually not true. It is such a safe surgery and we have such a low tolerance for risk in an elective eye surgery like this that we have literally made it risk-free in terms of anything the patient can do to cause a bad outcome.
The patient can put themselves at risk by being non-compliant with postoperative care. There are medications, prescription eye drops that are necessary. There are certain protective and common sense things that are required during the healing period. Barring that, it's almost risk-free and that really boils down to having a good conservative screening process that steers away people who are better served by wearing glasses or contact lenses.
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When you think of a lens, you probably think of the glass window on the front of a camera. But your eyes are a little bit different. Dr. Tom Miller talks with ophthalmologist Dr. Bala Ambati about…
September 16, 2015
Dr. Miller: Do you know the difference between the cornea and the lens of your eyes? We're going to talk about that next on Scope Radio.
Announcer: Access to our experts with in-depth information about the biggest health issues facing you today. The Specialists, with Dr. Tom Miller, is on The Scope.
Dr. Miller: Hi, I'm Dr. Tom Miller and I'm here with Bala Ambati, and he is a Professor of Ophthalmology here at the University of Utah. Bala, tell us a little bit about the difference between the lens of the eye and the cornea of the eye for those who maybe don't know much about that.
Dr. Ambati: No one in the listening audience probably remembers a film camera, but the camera has many parts to it. Just like a camera, the eye has a focusing part in the front of the eye, and the film of the camera, in the case of the eye, is the retina.
Dr. Miller: The back of the eye.
Dr. Ambati: The back of the eye, exactly. So if you look just at the front part of the eye, there are two main structures that focus light: the cornea, which is the front clear window of the eye. And that's the part that sparkles when you're sitting across somebody that you care about in a romantic restaurant.
Dr. Miller: That hasn't happened for a while, but I like the idea of it.
Dr. Ambati: And then behind that . . .
Dr. Miller: Not true, not true. For my wife, if she's listening.
Dr. Ambati: Behind the cornea is the colored part of the eye, the iris, and behind that is the lens. And the cornea actually provides protection for the eye. It's the clear window of the eye. It provides two-thirds of the focusing power of the eye.
Dr. Miller: The cornea does?
Dr. Ambati: It does, more so than the lens. The lens provides the last third, but the lens provides what's adjustable. The lens is what helps you focus from distance to up close and then back out again. And so the lens provides the swing, in terms of accommodation and in terms of changing focus, and the cornea is providing structural protection and most of the focusing power.
Dr. Miller: So it sounds like the cornea is the anterior-most portion of the eye . . .
Dr. Ambati: Indeed.
Dr. Miller: Or the portion that is exposed to the environment . . .
Dr. Ambati: Absolutely.
Dr. Miller: So this is the part that can become dry or irritated. There can be problems with allergies. It's the front-facing piece, is that correct?
Dr. Ambati: Absolutely. The cornea is the window of the eye and it has to protect the rest of the eye from anything that hits it, whether it's speeding steel or allergy or infections.
Dr. Miller: So also, the cornea is exposed to tears and tears, I guess, lubricate the cornea and the eyelids. Is that . . .
Dr. Ambati: Indeed. The eye works because you have all of these intricate structures working together. The eyelids provide a windshield wiper as well as producing tears, which lubricate the cornea and keep it smooth.
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The eyes stop growing when most people are in their twenties. By then, most people have a stable prescription for contact lenses or glasses if they need it. So if you suddenly notice your vision is…
August 18, 2015
Dr. Miller: Your vision has been changing rapidly over time, could that be a problem with you cornea? We're going to talk about that next on Scope Radio, and I'm Dr Tom Miller.
Announcer: Access to our experts with in-depth information about the biggest health issues facing you today. The Specialists with Dr Tom Miller is on The Scope.
Dr. Miller: I'm here with Balamurali Ambati, and he's a professor of ophthalmology here at the University of Utah. And we're going to talk a bit about problems that arise with the cornea, which is the foremost part of the eye that faces the environment.
Dr. Ambati: The cornea is the front window of the eye, and it has layers to it. Even though it's very thin, it's only about 0.5mm thick, it has five different layers. And the two most common problems of the cornea are a condition called keratoconus, where the cornea changes from its normal spherical shape into more of a cone-like shape.
Dr. Miller: And it does this over time?
Dr. Ambati: And it does this over time. And usually it does this in the late teenage years, 20s and 30s. So it's a condition primarily of young adults who may know or report that the eye has been unstable and changing. Most people, the eye stops growing by age 20 or 21, and the prescription...
Dr. Miller: Like the bones almost.
Dr. Ambati: Exactly, the prescription is stable. But if someone's astigmatism is changing... Astigmatism is when the cornea is shaped more like a football than a perfect sphere. That can be an early sign of keratoconus, and patients might report needing to go from soft lenses to soft toric lenses, or to hard contact lenses. They might report increasing near-sightedness and increasing astigmatism over the course of years. And this is something that is often undiagnosed till late stages, and so if you do have an unstable refraction or fluctuating vision over time it would be wise to get a cornea scan with an ophthalmologist.
Dr. Miller: What's the difference between, as you mentioned, fluctuating eyesight and progressive worsening of vision? Can you give a definition of that? I know you mentioned that when we talked about keratoconus as a problem.
Dr. Ambati: In fluctuating vision, which can occur especially in Fuchs' Dystrophy, the vision is different between morning and afternoon. In progressive loss of vision over the course of years, people recognize that their vision was not as bad a year ago, or two years ago.
Dr. Miller: The end result of that would bet at some point perhaps the contacts and lenses are no longer are effective in changing the vision, would that be the end stage?
Dr. Ambati: That can occur. The end stage of keratoconus requires what is called a cornea transplant, to replace the cornea with a donated cornea from someone who's passed away and donated their eye. Fortunately now, in the last five years, we've really changed the management of keratoconus to where we can prevent advancement from mild or moderate keratoconus to advanced keratoconus.
With things like intacs, which are rings that are placed inside the cornea that provide structural support, they're essentially an under-wire for the cornea to change it from a cone to a sphere. As well as the emerging technology of cross-linking, where we use a laser to stiffen the cornea and prevent weakening of the cornea.
Dr. Miller: So there are different options in the treatment?
Dr. Ambati: Very much so.
Dr. Miller: So is this a hereditary problem?
Dr. Ambati: It is a hereditary problem with what's called variable penetrance. So if you have a first degree relative with it you're at a higher risk for it.
Dr. Miller: Somewhat like glaucoma.
Dr. Ambati: Indeed.
Dr. Miller: And so if someone has a family history of keratoconus should they seek out an ophthalmological examination and a cornea scan?
Dr. Ambati: I think that would be advisable if they have any significant near-sightedness or astigmatism. And certainly it would be advisable if they are considering LASIK. One of the things that we do at Moran Eye Center is to carefully screen patients coming in for potential LASIK or laser vision correction to make sure they don't have keratoconus or other cornea problems.
Dr. Miller: So just to be sure, if one has keratoconus does it always require a transplant or is there, as you said, variable stages of the development of the problem?
Dr. Ambati: It is definitely a spectrum of progression, and if we can catch it in the mild or moderate stage the goal would be to employ intacs, or cross-linking, or some of these other options to prevent the need for cornea transplant.
Dr. Miller: Are there any other problems with the cornea? I notice since the cornea is the forward facing part to the environment, UV radiation, sunlight, does that affect the cornea more so than other parts of the eye such as the lens or retina?
Dr. Ambati: Certainly patients who are exposed to a lot of sunlight and UV light can develop pterygium, which is a growth on the surface of the cornea.
Dr. Miller: So that's a result of UV exposure sometimes?
Dr. Ambati: Indeed. And the UV radiation can also damage the back layer of the cornea, which is the endothelium. And those cells are actually what's called post-mitotic, they can't replace themselves. And so that can contribute to a condition called Fuchs' Dystrophy, where the cells of the back of the cornea slowly die. And that does require a partial thickness cornea transplant, but not a full cornea transplant, just replacing the back layer of the cornea. And those two conditions, Fuchs' Dystrophy and keratoconus, are probably the two most common causes of needing a cornea transplant procedure.
Dr. Miller: So in summary, would it be advisable if one has a family history of either of these problems to probably seek an ophthalmologic examination sometime in their 20s, or perhaps if they are having changing vision or astigmatism?
Dr. Ambati: Yeah, if you have fluctuating vision it is advisable to see an ophthalmologist at any time of your life. If you have a family history of keratoconus, in your brothers, sisters or parents, I think it would be advisable to see an ophthalmologist in the early or mid 20s. And if you have a family history of Fuchs' Dystrophy, that usually presents itself in the 40s or 50s, so that would be the best time to present.
Dr. Miller: Untreated what would be the end result of this if it continues untreated?
Dr. Ambati: Without therapy you would eventually lose vision, your eye would become cloudy and scarred. But generally people come well before that.
Dr. Miller: Thank you very much.
Dr. Ambati: Thank you.
Announcer: TheScopeRadio.com is university of Utah Health Sciences Radio. If you like what you heard, be sure to get our latest content by following us on Facebook, just click on the Facebook icon at TheScopeRadio.com.
Dr. Wolfgang Baehr, a professor of ophthalmology who has spent his career researching the genetic causes of blindness, says you have to be fearless to make advances in science. He talks about the…
April 25, 2014
Announcer: Examining the latest research and telling you about the latest breakthroughs, the science and research show is on the Scope.
Interviewer: My guest Dr. Wolfgang Baehr says you have to be fearless to make advances in science. He researches the genetic causes of blindness and has just been given a career award from ARVO, the Association for Research in Vision and Ophthalmology. You've been in the same field for about 30 years..
Dr. Wolfgang Baehr: Almost 40.
Interviewer: Almost 40..
Dr. Wolfgang Baehr: 1976.
Interviewer: Oh, right. 1976, yeah. What has been the most exciting moment of your career?
Dr. Wolfgang Baehr: Well, it's kind of hard, I have published about 200 papers, each one was a major, not each one but most of them were hard work. And, in the last 5 years I discovered it is very difficult to publish, even, a good paper. One of my best papers in Nature Neuroscience about two years ago, we worked five years on this project. And tried eight different [terms], we started with a top major in science, and it was very frustrating. But, eventually, we got it published in Nature Neuroscience. It was a wonderful paper and that was very satisfying. So persistence is something which is really my characteristic. We don't give up.
Interviewer: Do you think that you approach science any differently than some of your colleagues?
Dr. Wolfgang Baehr: Well, I think I do because I'm trained as an organic chemist, with basic science education and when I finished my PhD I basically decided to drop chemistry and learn something else, and I got into biophysics, fast kinetics, Stopped-flow kinetics and eventually into biochemistry. And then I came to the United States as a post doc and got into retinal research, so that's really when our research started back in 1976. During that time we started to work on phototransduction, which is the mechanism that starts to generate an electrical impulse in the retina, which is transmitted through the optic nerve to the brain, which is initially [meant] for vision.
Interviewer: What are some of the most striking ways that your field has changed over the last 30 years?
Dr. Wolfgang Baehr: At that time phototranduction was completely unknown, and at that time biochemistry was the thing to do to identify [inaudible 00:02:23] to identify G-proteins like transducing and eventually the main components we identified and then molecular biology started, DNA sequencing became possible in the 1970s, so I was one of the first starting sequencing trials, in [inaudible 02:46] for example. And then in 1990 the first mutation linked to autosomal dominant retinitis pigmentosa was identified in rhodopsin. And we decided to take this mutation, make the same mutation in mouse, and the mouse would [generate] the molecule internally to transgenic mouse, which was really not easy in those times.
Interviewer: One impression that I have is that you're not afraid to jump in with both feet.
Dr. Wolfgang Baehr: You have to be fearless. And just try and go and see this new gene published and new mutations. So we are very quick to make a knockout because it's relatively easy in mice.
Interviewer: Well, right, and this is something that seems to make you stand out from others..
Dr. Wolfgang Baehr: Yes.
Interviewer: Is that you do make these mouse models for genetic retinal diseases.
Dr. Wolfgang Baehr: We've probably knocked out 20 different genes in the last 10 years, and many of those models were first and unique. Nobody had ever produced any of those mice.
Interviewer: Can you give one example of a mouse model and what defects it had and how you were able to reverse some of those?
Dr. Wolfgang Baehr: Well, the best mouse model would be the dominant disease caused by a mutation in a calcium binding protein, which is called guanylate cyclase activating protein, called GCAP for short.
Interviewer: So, basically, if there's a mutation in this GCAP it causes a dominant disease and the protein is overactive, correct?
Dr. Wolfgang Baehr: Protein is overly active, but using a molecule cGMP, which is damaging photoreceptors. We depend on cone vision for color vision, acuity, reading newspapers is all dependent on cones, and this disease destroys first, cones. So, you basically become photophobic because light intensity is very damaging. And you start having problems with reading newspapers, begin central vision problems and you wear sunglasses. So it's very difficult for patients to very slowly lose cone vision and visual acuity and then slowly becoming blind. And mice being inoculated with AV virus that knocks down the mRNA...
Interviewer: When you're knocking down the mRNA, what happens is that there's less protein being made, right?
Dr. Wolfgang Baehr: It's less damaging protein being made and the [inaudible 05:22] of the retina is not damaged.
Interviewer: Right. So, you're taking away the problem in the first place.
Dr. Wolfgang Baehr: We can slow down the damage and have a very positive effect after one year, in terms of visual acuity and cone photo function is way improved. So in a mouse model it works beautifully, and the additional advantage that we have with this construct is that it is applicable to any mutation in GCAP, there are about 2,000 families worldwide, which have been identified so far, with 100 to 150 patients. All of those patients could use the same [inaudible 06:01] virus with our knock-down construct and could have beneficial health experiences and slow down the disease dramatically. The point where we are right now is, is it worthwhile to do clinical trials, there's a very small patient collection...
Dr. Wolfgang Baehr: In different parts of the country or the world. And, as you know, will there be a company that supports us, and that's the question I don't know.
Interviewer: Another aspect, of course, of your work is that you're understanding the whole process of phototransduction and getting new insights into how that works..
Dr. Wolfgang Baehr: Yes, how that works. In the beginning we know all details, and my interest really, is to understand mechanisms leading to disease, and I think we might essentially, each gene is a new area, [of possibilities]
Interviewer: What keeps you fascinated in this work?
Dr. Wolfgang Baehr: Because there's always something new. We've focused, of course, at genes very specific for photoreceptors, but eventually we got into [Centronics dystrophy] like effecting multiple tissues. You know, cut a gene and some of those genes would cause embryonic lethality, mice would never be born; or would die early. And, of course, that's much more complicated, you cannot do just retinal research, you have to look into kidneys, for example. And that is, of course, not my field, so I need collaborators.
Interviewer: Yeah. Yeah.
Dr. Wolfgang Baehr: But that makes it more interesting because those diseases are very, very devastating. But it's also expanding research and making it more interesting, you know. Getting into new areas, being [fielders] and being persistent I think that's the characteristic in which we can demonstrate.
Announcer: Interesting, informative, and all in the name of better health. This is The Scope, health sciences radio.
The Moran Eye Center has been involved in many of the key clinical studies for age-related macular degeneration. Dr. Paul Bernstein talks about the primary treatment for AMD, how it works, and how…
April 23, 2014
Man: Medical news and research from the University of Utah physicians and specialists you can use for a happier and healthier life. You're listening to The Scope.
Interviewer: Dr. Paul Bernstein at the Moran Eye Center. Let's talk about some of the trials and some of the work and research that have been done into AMD and what you've discovered.
Dr. Paul Bernstein: Okay. We at the Moran Eye Center have been very involved in many of the key clinical studies for age-related macular degeneration. One of our primary treatments is a drug called Lucentis, which involves injections once a month of a medicine into the eye every month for age-related macular degeneration for the wet form.
Interviewer: And that's where the veins are starting to come into the eye?
Dr. Paul Bernstein: That's correct.
Interviewer: What does this medication do? Does it just stop that?
Dr. Paul Bernstein: The Lucentis and similar drugs, when injected into the eye, combat the growth of blood vessels. They actually interact with the signal to grow blood vessels, a compound called VEGF or vascular endothelial growth factor.
Interviewer: We learned in our previous podcast that what's going on there is that those cells are sending those signals to grow those blood vessels, and this tells it to stop.
Dr. Paul Bernstein: Yes.
Dr. Paul Bernstein: It just blocks the signal right there.
Dr. Paul Bernstein: It binds them, and the signal can no longer interact with the receptor to grow the blood vessels, and the blood vessels that are abnormal begin to get smaller and kind of wither away. After the drug wears off in a month or so, we have to give another injection into the eye.
Dr. Paul Bernstein: We would love to have a drug that could be just given as an eye drop. As you know, we have many medicines we give as eye drops. The challenge is that the retina is the back of the eye, and trying to get a drug to go all the way back and interact with the retina is difficult. Drug companies are very actively trying to improve that process.
Interviewer: So I suppose a pill, an orally taken thing, is just completely out of the question?
Dr. Paul Bernstein: People are looking at pills for macular degeneration that could combat the growth of blood vessels. The process is the macula and the eye is a very small part of the body.
Dr. Paul Bernstein: You have to worry about side effects and other reactions.
Dr. Paul Bernstein: We certainly like the idea of local delivery, of targeted delivery to the eye.
Interviewer: Yeah. That's interesting. And what other kind of research of trials are you involved in or do you have going on?
Dr. Paul Bernstein: Well, we were one of the centers for the Age-Related Eye Disease Study, too, the AREDS 2 Study. We're really trying to understand the role of nutrition and nutritional supplements in age-related macular degeneration. This was a very large trial. There were nearly 100 centers across the country. Over 5,000 patients were in the study. It lasted five years. They had to come in every few months for eye examinations and to be given their supplements or placebos. It was definitely a placebo-controlled trial to really understand how these supplements work.
Interviewer: In a situation like that, I think you gave me a hint. How would you even know where to start and what to look for as far as nutrition that might be helpful? It sounds like you said these two things are high concentration in the eye, and that's where you started.
Dr. Paul Bernstein: Yes. So, the lutein and zeaxanthin are particularly interesting because the macula, which we all hear about for macular degeneration, is technically the macula lutea, which means "yellow spot" in Latin. And the macula uniquely in humans and fellow primates concentrates yellow compounds from our diet, the lutein and zeaxanthin. So I was always fascinated as to why nature went out of its way to put these two compounds that are antioxidants and light screening compounds directly into the back of the eye.
Interviewer: So somebody would take this supplement, and you would look to see if the concentration increased in their eye. Is that what you were looking for?
Dr. Paul Bernstein: That was in part. We were a sub-study in the trial to do measurements of the macular pigment levels, but ultimately for a national eye institute sponsored study, we're looking to see if it is effective with whether we can decrease the rate of progression to advanced age-related macular degeneration. That was the ultimate endpoint in the study. We have to see that we are getting an effect.
Interviewer: Yeah. Because if you increase those compounds, who cares if it's not solving the problem?
Dr. Paul Bernstein: That's exactly right.
Interviewer: Yeah. Interesting. What else do you have going on? You mentioned something on the horizon. Can you talk about that a little bit?
Dr. Paul Bernstein: We are looking at some other trials trying to interact with the immune system and the complement system. There is some exciting work as some of my colleagues here in the Genetics have discovered that the inflammatory system in the eye may be part of macular degeneration. So drug companies are developing new compounds that could interact with the complement system. Those are very early stage trials, and we're very hopeful that we can get involved in preventing macular degeneration earlier.
Interviewer: So what's the theory there with the inflammatory system that's causing the problem? Is that, like, inflammation in other parts of my body, but it's happening in my eye? What would cause that?
Dr. Paul Bernstein: Inflammation as part of macular degeneration relates, we think, to the formation of drusen, the yellowish deposits we see underneath the retina. That is a very important sign of early macular degeneration. This causes damage to the cells and also contributes to the stimulus of new blood vessel growth underneath the retina.
Interviewer: So the thought that this is happening in the immune system that's trying to fight it is actually causing more harm than good. Is that what I'm hearing?
Dr. Paul Bernstein: We think that there may be a problem, and modifying that, that's what we need to test in these trials.
Interviewer: Any final thoughts for our listeners about the future of research trials?
Dr. Paul Bernstein: We always are looking to improve treatments. We've been very gratified by the improvements that have occurred in the last two decades for macular degeneration. We especially appreciate the commitment that the patients who join these trials have committed to this to trying to help both themselves and to others.
Interviewer: Could somebody listening be part of one of these trials? How would they make that happen?
Dr. Paul Bernstein: They need to talk with their doctor.
Dr. Paul Bernstein: If you have macular degeneration, the best thing is to ask your doctor. Ask what trials are available, and how they could be improved on the standard therapy that we have now.
Man: We're your daily dose of science, conversation, medicine. This is The Scope, University of Utah Health Sciences Radio.
Age-related macular degeneration is the leading cause of blindness in the world. If you’ve had a relative with macular degeneration, you know how heartbreaking it can be to watch them lose…
April 18, 2014
Interviewer: If you've had a relative with macular degeneration you know how heartbreaking it can be to watch them lose their sight; and a little terrifying for you, too, because you've got to wonder if you're next. We're doing to discuss that next on The Scope.
Recording: Medical news and research from University Utah Physicians and Specialists you can use for a happier healthier life. You're listening to The Scope.
Interviewer: Coming up today on The Scope we're going to talk about macular degeneration. We're going to cover what it is, what are the risk factors that could help you get it, what you can do to prevent it, and some possible treatments. We're with Dr. Paul Bernstein of the Moran Eye Center.
Dr. Paul Bernstein: Yes, age related macular degeneration is the leading cause of blindness in the developing world. And there are two types and it affects the central part of vision called the macula. The macula is the area of the eye that is responsible for reading, driving, recognizing faces, and in age related macular degeneration there is a dry form, which is a slow form that progresses slowly over years if not even decades, it can eventually lead to central blindness in the eye.
Interviewer: So the dry form, what exactly is happening in the eye?
Dr. Paul Bernstein: In the dry form initially it starts with deposits forming underneath the retina; something that we call drusen that are yellowish spots under the retina. The patient may have completely normal vision, and not have any symptoms. But eventually there is more malfunction of the cells of the retina and some of them begin to die in the center of the macula and that is why the center of the retina no longer senses light properly, and that can lead to blindness.
Interviewer: So it's like a camera not being able to sense light?
Dr. Paul Bernstein: That's correct; it's a problem of a camera with bad film.
Interviewer: And in the wet you're actually getting some growth back there and that's blocking your vision?
Dr. Paul Bernstein: That is disturbing the vision.
Dr. Paul Bernstein: It's interrupting the retina from having contact with its supporting cells, and eventually this can damage both types of cells as these blood vessels get in between these two layers and they can bleed. They can leak fluid, and eventually they can form scars and that's what leads to loss of vision there.
Interviewer: What's going on? Why are those starting to grow there?
Dr. Paul Bernstein: We don't know completely, but we understand that with age there is some malfunction of the cells and they for reasons that we don't completely understand start sending out signals and that seems to be an important factor for causing these blood vessels to start to grow underneath the retina. So it's kind of a malfunction; it's the wrong signals being sent out, that's correct.
Interviewer: All right, so who is at risk for age related macular degeneration? I think the name kind of gives you some sort of an indication?
Dr. Paul Bernstein: Yes, there are many risk factors, and certainly age is one of the most important ones. We know that age related macular degeneration is not very common in the people in the 50 to 60 year old range. Only a couple percent of people show the signs, but as we age it rises almost exponentially so that over age 75 at least 30% to 35% of people show at least some signs of age related macular degeneration.
Interviewer: So it's hereditary, so if you get old enough you're just going to get it?
Dr. Paul Bernstein: Well, there are a number of important risk factors for age related macular degeneration. And these genes are risk factors and we know of two very important ones; one on chromosome 1 related to complement and inflammation. And another one on chromosome 10 that we still don't quite understand, but if you have the wrong combination of genes that you've inherited from your parents it can put you at much, much higher risk. It can raise your risk three, five, even tenfold higher than the average population.
Interviewer: How much do you know about the direct causation of diet?
Dr. Paul Bernstein: We know that diet is very important. And there is accumulating research that modifying diet can change the levels of the lutein and zeaxanthin which are from the dark green leafy vegetables that are actually accumulated in the eye. So we know that diet can make a difference, but as I said, when people are older changing their diet is difficult and that's why through the Areds 2 Study...
Interviewer: And what does AREDS stand for?
Dr. Paul Bernstein: AREDS stands for Age Related Eye Disease Study.
Dr. Paul Bernstein: And that most recently specifically looked at adding lutein and zeaxanthin, and omega 3 supplements to the vitamins that we already knew were effective against age related macular degeneration.
Interviewer: So what are some other things that you can do then? So you have these supplements, and do you really feel they are effective from what you've seen?
Dr. Paul Bernstein: I think they are, and I certainly . . . it's a big part of my practice, encouraging patients to take these supplements, because often my patients present they've lost vision in one eye, and they are very concerned that it's going to affect their other eye, because you can get by with good vision as long as you have good vision in one eye. But if you have age related macular degeneration that's significant in both eyes, it can be devastating to these otherwise well-functioning patients. We encourage them not to smoke. We also think that there is a negative role for excessive sunlight, so we encourage patients to wear sunglasses on bright sunny days. That's an easy thing to do.
Interviewer: And it sounds like all of these things that you're currently recommending are really pretty low impact? It's not like anything too serious. What's the risk of taking a few vitamins?
Dr. Paul Bernstein: We think that lutein, zeaxanthin, and the basic AREDS vitamins are very safe and few patients complain of side effects.
Interviewer: The wet form is actually treatable; dry form once it's started, not so much. Is that correct?
Dr. Paul Bernstein: That's correct. We are certainly looking at new treatments for the dry form, but currently the standard of care is just antioxidant vitamins and good diet.
Interviewer: Does the wet form always come before the dry form, or the dry form before the wet form?
Dr. Paul Bernstein: The dry form comes before the wet form. Okay, so and they almost always start with the dry form of macular degeneration, the slow form. The wet form can then rear its ugly head and we have to treat it and sometimes we get it back under control and still the dry form slowly progresses over time. Macular degeneration is a manageable disease; we'd like to make it a curable and a preventable disease, and that's what we're working on here.
Interviewer: If I have a family history of it can I get a genetic test and can you actually see if I have the gene mutations you were talking about?
Dr. Paul Bernstein: As a research tool, yes. We can and there are models that can predict that you have an increased risk. But it is I would caution a risk assessment, so not everyone even with the relatively high risk develops macular degeneration and other people develop macular degeneration for reasons that we don't completely understand. We are trying to figure out the role of the test still in clinical practice and in helping counsel people and that's part of further research that we will be conducting.
Recording: We're your daily dose of science, conversation, medicine; this is The Scope, University of Utah Health Sciences Radio.
Sometimes when you pay the doctor a visit, he’ll hold a little flashlight up to your eye and joke that he's looking into your soul. But what are doctors really trying to find when they…
October 31, 2018
Interviewer: What is a physician trying to find when they look into your eyes? That's next on The Scope.
Announcer: Medical news and research from University of Utah physicians and specialists you can use for a happier and healthier life. You're listening to The Scope.
Interviewer: A lot of times on TV you'll see, or if you've ever even gone to the doctor yourself, they got the little flashlight and they start looking in your eyes and I've always wondered, what are they looking for? We're with Dr. Troy Madsen, emergency medicine at the University of Utah Hospital. In your particular situation, in the emergency room, if you get out the light and are looking into somebody's eyes, what are you trying to figure out?
Dr. Madsen:It's going to vary depending on who I'm looking at. But it's just part of a standard physical exam that when I see a patient I will document something that says on the chart, PERRL. What that stands for is the pupils are equal and reactive to light. And the pupil is the black part of your eye so I'm looking at that. I'm looking at are they the same size, and when I shine a light into it does it close? Does it react to that light and constrict like you'd expect?
And the relevance of that kind of varies from person to person. I mean, in the average person, it's not really a big issue. I can just kind of look at you and look at your eyes and say, "Oh, yeah, they look fine." But in different situations I'm looking for different things.
So if someone comes in after a head injury and they've been in a trauma, I really want to get a good look at those eyes to make sure the pupils are equal, because if they're not, that can be the sign of potentially something very serious in the brain that is affecting the brain's ability to send that message to the eye to have that pupil squeeze down and constrict. That can be a sign of some kind of bleeding in the brain, which is the more serious thing I'm really looking for there. So that's kind of the number one thing I'm looking when I do that.
The other thing I'm looking for often times, and this is a tough thing to do sometimes in the E.R., but sometimes I'll try and get a look at the back of the eye at what's called the fundus of the eye, called a fundoscopic exam, where I'm looking at optic nerve, so where the nerve inserts into the back of the eye. And if a person has a lot of pressure in their brain from bleeding in the brain or something like that, I can actually see swelling on that nerve. So that for me says this person potentially has something that's raising the pressure in their brain, like bleeding, a tumor, something like that. So that's kind of the other big thing I'm looking for when I do that.
Interviewer: All right. So two reasons you would look into somebody's eyes, none of them related to the eyes. Are there things you're looking in somebody's eyes for if they have an eye issue?
Dr. Madsen: Oh, certainly. Yep. And that's one of these things where if someone . . . and usually there I need to have something that's going to push me toward that, someone saying I'm having a lot of pain in my eye or I feel like just something is scratching my eye. And there, I'm going to do an even more detailed exam. I'll kind of flip their eyelid out, kind of like kids do to gross people out. So I'm doing that to look for some kind of piece of dirt or a splinter or something like that in the eyelid itself that's scratching the eye.
Interviewer: And that actually happens?
Dr. Madsen: It does.
Interviewer: That's gross.
Dr. Madsen: Oh, it does, yeah. And then I'm looking at the cornea, so the front part of the eye and sometimes you'll look at that, you'll see little pieces of metal that are stuck on there, say, from a welder or someone who is working with metal. I can see that. Sometimes I'll see a rust ring there. You can actually see rust on the eye itself from a piece of metal that may have been there and then came off.
And then I'll do a very detailed exam, something called a slit lamp exam. It's basically a microscope where I'm sitting down kind of with this microscope that focuses right on the person's eye. I'm looking in the front part of the eye for any, what we call just any cells, any inflammation there that would suggest a lot of irritation in the eye itself. And then I actually put a little thing on the eye that's kind of like a dye that will light up to look for any scratches.
Dr. Madsen: Which is what's called a corneal abrasion.
Dr. Madsen: So lots of different things you're looking for there on the eye.
Interviewer: So any of these tricks that people can try at home? For example, taking the flashlight and if a person's pupils aren't dilating properly, knowing that you might potentially have an issue?
Dr. Madsen: Yeah, and that's something you can do. If you've had a head injury and you feel comfortable looking at that, you can even look at your own eyes in a mirror and just say, "Do my pupils look like they're the same size?" If you have a family member who's had a head injury, you can shine a light in their eye, just watch, does that pupil squeeze down? And at the same time that one squeezes down does the other one do the same thing? And if it's not, those are concerning things.
Interviewer: Is time of the essence for any sort of eye injuries, generally?
Dr. Madsen: It is, yeah. So time is really of the essence for eye injuries if you actually have something that cuts the eye open. So if we have what's called an open globe injury, so the globe being the eye, the big eyeball, if something actually gets in there and cuts that where there's fluid coming out, time is absolutely of the essence. You need to get to the emergency department. We call our ophthalmologist and they'll oftentimes get you to the operating room to repair that emergently.
Interviewer: All right. Any final thoughts on the eyes?
Dr. Madsen: Final thoughts on the eyes. Obviously, a lot of these things are things we are going to need to do in the E.R. but, like you said, you can kind of take a look at the eyes at home. And certainly if anything comes up, make sure you come in so we can evaluate you further.
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You might think dry eye disease is a result of simply having a lack of tears. The condition is actually an inflammatory disease. Dr. Majid Moshirfar explains the causes of dry eye disease —and…
October 08, 2013
Host: Fall? Dry eye season? What do you do about it? First of all, we're going to find out what causes it. Second of all, we're going to find out what you can do about it, including maybe some things you've never heard of before.
Announcer: Medical news and research from University Utah physicians and specialists you can use for a happier and healthier life. You're listening to The Scope.
Host: We're talking to Dr. Majid Moshirfar from the Moran eye center. So tell me, dry eye syndrome. I know this seems like a simple question and a silly question but, what is it?
Dr. Majid Moshirfar: No, there is no silly question. Indeed, dry eye syndrome, or what people call dry eye disease, is an inflammatory disease process. Very interestingly, we all thought that if somebody had a dry eye, it simply meant that they have insufficiency of their tear film. That was the naive thinking that we all had in the 1960's and 1970's and 1980's. But thanks to some very good clinicians and symposiums, now we believe that dry eye disease is an inflammatory process that happens on the surface of the eye on the ocular surface.
Host: That's interesting. It's a disease; it's not just a condition.
Dr. Majid Moshirfar: No, it is actually a disease.
Host: So, redefining what it is really probably redefines what I would do about it. I would think, if I have dry eyes, I go to the store, I get some eye drops. I keep dropping them until I feel better.
Dr. Majid Moshirfar: And that's actually the wrong that you can do. Because when you go into the store and you look in the hygiene section and look at the eye section, and you choose some of those artificial tears, that's what you're talking about. Some of those artificial tears, many of them actually have preservatives in them. And if you keep putting those artificial tears with the preservative inside your eye, you're actually going to create a secondary allergic reaction to the preservatives that are inside it.
Host: You're making it worse.
Dr. Majid Moshirfar: Yes. You did the right thing by choosing artificial tears, but you have been putting in tears that have a lot of preservatives in them and that is not the right thing to do. You need to look for artificial tears that are preservative-free.
Host: And those are okay?
Dr. Majid Moshirfar: Those are absolutely what we recommend our patients, that's our first line of defense against dry eye disease.
Host: So then would you, if you had dry eye disease and this is the first line of defense, is this something that you would use for the rest of your life then, or just as...
Dr. Majid Moshirfar: It's very interesting, because it's just like any disease, any prevention that we can do. I think nowadays medicine is about prevention and about educating. If you see my patients who are in their 30s and 40s, if these individuals approached them nicely in the beginning, all you need is maybe one or two drops a day. Maybe in the morning and maybe in the afternoon. But when you see somebody who is 80 years old, and they've had all these problems for years and years, they've already destroyed a lot of the surface integrity, a lot of those stem cells, a lot of those what we call goblet cells or mucocele cells. So what happens is that it's very important that we start tackling ocular surface inflammatory disease early on.
Host: I had Lasik done, and they did something. They plugged my tear ducts. Is that something that can be done?
Dr. Majid Moshirfar: Right. And as I told you, when people have dry eye disease because of whatever reason, whether it was Lasik, or thyroid eye disease. When you have a bad flu or pneumonia and you're taking a lot of sinus medications to get rid of your nasal congestion.
Host: What about foods that you eat? Could that cause dry eyes? Alcohol? Stuff like that?
Dr. Majid Moshirfar: Absolutely. Poor diet. I really really believe that people who have a very poor diet with a poor balance of their nutrition can have dry eyes. And I see this many times. Patients who come to me and they've been on a rigorous diet, to lose 50, 60, 100 pounds. And I see them, they actually develop what I call a secondary ocular surface dryness. So you need to have a well-balanced diet. We recommend a lot of our patients to take fish oil in order to improve the status of their tear film.
Host: Okay, so we talked about the proper eyedrops, without the preservatives, we've talked about possibly plugging the tear ducts which is something else that can be done. What are some other procedures if those aren't working?
Dr. Majid Moshirfar: One of the things that we do is first of all you need to catch the patients at the earlier stages of dry eye, and then -
Host: Yeah, because it gets worse as you go on.
Dr. Majid Moshirfar: Absolutely.
Host: I mean, if you don't catch this right away, it's just getting worse and worse.
Dr. Majid Moshirfar: It's like a patient who has a bad joint or a bad rheumatoid arthritis.
Host: That's new, that's news to me.
Dr. Majid Moshirfar: Yes. And so rheumatoid arthritis, if you don't take care of them, they get to a point where they need to have a total knee replacement and more. So it's important to catch that earlier stage. So to answer your question, we are very fortunate because now we have some medications that we actually prescribe by prescription that you can actually pick up from a pharmacy, and these medicines are very good at improving the secretion of your tear film. So we are actually not encouraging people just to use artificial tears. We actually make your own glands to make tears in your eyes. And one of them is called Restasis. We use very safe cortical steroids to put inside your eyes to encourage the secretion of your tear film and also reduce the inflammation of the ocular surface. So, yes, there are medications we can implement, there are punctal plugs, humidifiers at the working environment or at home, some little humidifier next to your bedside. A lot of these things can also help as well.
Host: And I read, this sounds crazy to me, about an implant that actually, you called it a little gummy bear.
Dr. Majid Moshirfar: That's right. They're called Lacrisert, and they're amazing. There are some patients that need this little tiny gel, almost like a little tiny capsule if you want to think about it. Like a very small, small, small, small gummy bear that you actually put underneath your lid. You tuck it underneath there, and it's like a little tiny capsule of gel that secretes a lubricating substance throughout the day and keeps your surface completely moist. And all you have to do is, you put this Lacrisert in at the beginning of the day, and it goes all the way, 24 hours. So they're very rewarding for some patients.
Host: Oh, so that's just something that a person puts in every day.
Dr. Majid Moshirfar: That's right. Yes.
Host: So I go into my eye doctor, what do I need to tell them so they know what I'm talking about?
Dr. Majid Moshirfar: First of all, I think when you see your doctor, most of the eye care physicians are very astute about this. They know what to do, they have some tests.
Host: It's a fairly common thing now.
Dr. Majid Moshirfar: Yes. As a matter of fact, 80% of most ophthalmologic visits, one of the complaints that the patients have is in a way related to ocular surface dryness. Now maybe not the disease, but a mild spectrum of that.
Announcer: We're your daily dose of science. Conversation, medicine. This is the Scope. University of Utah Health Sciences Radio.