General Ophthalmology
A cataract is not a film that spreads across the front of the eye or a growth that gradually enlarges. A cataract is a progressive clouding that occurs in the clear lens of the eye. The lens is located inside the eye, suspended just behind the colored iris, and functions to help focus eyesight as light passes through the pupil. In younger years, the lens is elastic and can change its shape to allow the eye to see clearly both at distance and at near. But as we age, the lens gradually hardens and loses its elasticity (and we have to get reading glasses), and then begins to cloud, creating blurred vision. It is this clouding that is called cataract. Left alone, cataracts can become so clouded that a person can be blinded. Cataracts are a leading cause of blindness in third world countries even today.
There is no medical treatment for cataract, only surgery, which is done when vision has become noticeably blurred and is interfering with daily activities. Fortunately, cataract surgery has evolved into a highly successful and gratifying procedure. Gone are the days of long hospital admissions with immobilization of the patient, large incisions, stitches and thick cataract glasses. When today's patient has enough vision impairment to require cataract surgery, it is an outpatient procedure that often takes less than 15 minutes, done through a tiny incision, no-stitch using a thin ultrasound probe that breaks up and gently removes the lens. Sharp focus is then restored by the implantation behind the pupil of a new lens, man-made, called an intraocular lens (IOL). This synthetic implant made of medical grade silicone or acrylic plastic, is custom selected for each patient, and often has better optical quality than the natural lens. Many patients state they have never seen so well, even in their younger years. Recent developments in implant technology now allow our patients to opt for Deluxe IOLs that provide even better optics, and can restore the eye's ability to see clearly both in distance and at near.
Corneal Disease - The cornea is the clear round dome on the front of your eye. It is the window through which light must first pass. The cornea's health is critical to clear vision. It must be tough, as it is part of the outer protective cover of the eye, but at the same time must be crystal clear, smooth, and moist in order to function as the strongest focusing element in the eye. The surface of the cornea is kept clear by our tears, and will quickly dry and cloud if tears are deficient or the eyelids are prevented from blinking or closing. Please read below about dry eyes, and the importance of keeping the cornea moist. The surface of the cornea can be clouded by infection. Viruses and bacteria occasionally penetrate the delicate surface lining of the cornea, and if untreated, can leave cloudy scars through a process called ulceration. The most common cause of corneal ulceration is trauma causing a scratch or erosion. Contact lens wearers occasionally scratch their corneas, and must be meticulous in hygiene and technique to prevent ulceration. They must faithfully replace their old lenses when scheduled, lest debris and deposits abrade, and must be careful to be sure their solutions do not become contaminated. Any scratch, whether caused by a branch, a fingernail, or a foreign object will carry an infection risk to the cornea, and should be evaluated and treated by your doctor. The cold virus (Herpes Simplex) and the shingles virus (Herpes Zoster) are exceptions, and can invade the cornea without trauma. Scratchy pain, light sensitivity, and blurred vision are typical symptoms. The cornea can be clouded by hereditary dystrophy, in which a gene defect will lead to loss of clarity or integrity. The multiple forms of dystrophy are generally classified according to their location in the cornea, and may be mild or severe, painful or not. Some are simply observed, some require drops, and a few cause enough vision loss to require cornea transplantation. Examples of corneal dystrophy are Fuchs', anterior membrane (also called map-dot-fingerprint), and keratoconus or conical cornea. Most dystrophies are detected during the course of your periodic eye exam, as they are visible to the doctor when he looks at your cornea with the microscope.
Corneal Abrasion - Painful! Usually caused by trauma, loss of the corneal surface lining will definitely get your attention. A scratch from a twig or branch, fingernail, a paper edge, contact lens, or a foreign object blown in from the air, the common problem is a defect in the corneal surface lining. This little raw spot is exquisitely painful and is an avenue for infection (see above). Fortunately, the surface cells recover quickly and efficiently in most cases. Your doctor or ER physician will first examine to be sure the abrasion is only superficial, and then recommend an antibiotic, and may patch close the eyelids to speed healing if the abrasion is large. Never use a surface anesthetic eye drop for pain control, as this medication is toxic to the healing cells. A poorly healed or infected corneal abrasion can lead to permanent scarring and loss of vision.
Diabetic Retinopathy - Diabetes Mellitus is primarily a disorder in the way we handle the sugar that we eat, usually from lack of insulin or inability to process it. Fluctuating blood sugar levels can gradually induce blood vessel damage, such that diabetics have a higher risk of vascular disorders such as heart attack, stroke, peripheral vascular disease of the extremities, renal (kidney) failure, neuropathy, and retinopathy. Diabetic retinopathy affects the blood vessels of the retina of the eye, causing them to be weak and leaky. This can lead to hemorrhaging, swelling (edema), oxygen deprivation, and abnormal vessel growth. Blurred vision, floaters in the vision from internal bleeding, and even loss of vision to the point of total blindness are potential risks, if left untreated. Unfortunately, early retinal abnormalities may not be noticed by the patient, as they are painless. However, these vascular changes in the retina are readily visible to the ophthalmologist during the course of your eye exam. If you have retinopathy, your EyeMD will grade its severity, and may recommend treatment if it has reached well established criteria. Normally the treatment consists of laser (light) therapy to leaky vessels, closing them, or a more extensive laser treatment for abnormal vessels to prevent hemorrhaging. Laser therapy for retinopathy is one of the most effective treatments in all of medicine. As the best outcomes come from early detection, a regular schedule of retinal exams will be recommended, at least yearly as recommended by both the American Academy of Eye Physicians and Surgeons as well as the American Diabetic Association. Modern diabetic treatment and a better understanding of dietary measures and exercise permit diabetic patients a better opportunity to live full and normal lives. The incidence of diabetic blindness has decreased progressively as a result.
Droopy eyes (Dermatochalasis/Ptosis) - A droopy eyelid in a patient who was previously normal is usually caused by excess skin and fat appearing just above the eyelashes as we age (dermatochalasis). Generally thought of as a cosmetic problem, dermatochalasis can sometimes be so severe that the eyelids hang down into the vision. This excess tissue can be removed to improve appearance and visual function, and is the most commonly performed type of eye plastic surgery. This surgery can be performed at Narrows Eye Surgery Center as an outpatient. Ptosis refers to a droopy eyelid in the absence of excess skin/fat. Ptosis is due to a failure of the eyelid levator muscle to lift the lid properly. Often ptosis is congenital, but may appear because of aging, injury, thyroid disease, or (rarely) tumor formation. If mild, ptosis is usually observed without treatment. If more severe, the levator muscle can be shortened to elevate the eyelid.
Dry Eye - Proper lubrication is critical to the health and clarity of the clear cornea of the eye (see corneal diseases above). Oily tears and mucus, spread across the cornea by our eyelids as we blink, are constantly produced by glands in the lids and delicate lining of the eye (conjuctiva). Also, watery tears produced when the eyes are stimulated by an irritant, or when we cry, add additional protection and come from the lacrimal gland beneath the upper eyelid. Lack of proper tear production or eyelid closure quickly leads to burning, grittiness, and light sensitivity, symptoms of dry eye and exposure. Left untreated, dry eyes can lead to painful keratitis sica and permanent corneal scarring. The gradual loss of tears occurs with the aging process, and in most cases is a mild condition responding to artificial tear drops. In some, the tear film is abnormal due to eyelid infection, especially blepharitis. An eye exam will determine whether blepharitis is present. It must be specifically treated or the dryness will persist. Sometimes dry eyes occur due to lack of blinking, often a problem in those who intently read or do computer work, or who wear contacts. Smoking, low humidity (as in our homes during the cold winter months), dehydration, and certain oral medications are contributing factors. More severe dry eye can come from medical conditions such as Sjogren's Syndrome (loss of tear glands in rheumatoid arthritis or lupus patients), chemical conjunctival burns, severe conjunctival damage from infection or allergy (Steven's-Johnson Syndrome), pemphigold, and eyelid closure disorders such as Bell's palsy or excessive botox, as well as loss of corneal sensation caused by the nerve damage of shingles or herpes simplex, or by tumor or stroke. When more aggressive lubrication is required, your doctor has a variety of options such as viscous geltears, plugs to close the drainage of tears from the eye, and more recently eyedrops (Restasis) than can restore tear production in some patients. Rarely, patching or surgery may be required to close an eyelid in order to protect the cornea.
Blepharitis - Blepharitis means eyelid inflammation or infection. Blepharitis is in fact the most common eye infection encountered. It occurs when the margin of the eyelid becomes overly infested with normal skin bacteria. The lid then develops redness, crusting, and loss of eyelashes. The patient develops symptoms of burning, dryness and itching. Blepharitis is not due to poor hygiene in most cases, but can occur in anyone, especially those with a condition called acne rosacea. Blepharitis is generally obvious and can be diagnosed by the doctor by using a penlight, but occasionally is subtle and microscopic evaluation is required. The hallmark of treatment for blepharitis is moist compresses and eyelid cleansing using a gentle shampoo. Baby shampoo works well, but can be drying. Alternatively, there are cleansing pads specifically formulated for this purpose. If more severe, antibiotics may be needed, either topical or oral as determined by the ophthalmologist. Blepharitis has a strong penchant for recurrence, such that some require chronic therapy. Treating blepharitis is particularly important in managing the dry eye patient, in succeeding with contact lenses, and prior to eye surgery such as cataract removal, where spread of bacteria into the eye can be sight threatening.
Flashes and Floaters - Flashes or flickers of light in one or both eyes, or floating spots or strings in the vision can be normal, or can be symptoms of serious eye disease. Generally these symptoms are a harmless nuisance caused by aging changes in the gel part of the eye called the vitreous. Floaters are best seen when looking at a brightly illuminated background such as the ceiling, the sky, a snow field, a putting green, or sometimes even when reading. Most older individuals have floaters, and they can occur earlier in nearsighted people. However, if floaters suddenly increase in number in one eye, especially if preceded by sparky flashes of light, they can also be a symptom of a serious retinal condition, and should be promptly evaluated by the ophthalmologist.
Glaucoma - Glaucoma is known as “the sneak thief of sight.” Progressive atrophy of the optic nerve in the back of the eye is the hallmark of this condition. Glaucoma is an often poorly understood group of diseases whose common thread is optic nerve damage. Simply stated, glaucoma occurs when the intraocular pressure (IOP) becomes too high for the optic nerve, causing ischemia (loss of circulation). The nerve gradually dies off, and with it, the vision progressively dims, and if left untreated the eye becomes permanently blind. There are multiple causes of elevated IOP. In many it is hereditary as it often runs in families, and is more frequent in African-Americans and Asians. In some, elevated IOP is secondary to eye inflammation or injury, whereas in others certain anatomical variations such as narrow angle, high myopia, pigment dispersion, and pseudo-exfoliation are associated. Elevated IOP is more common in diabetics and in some who require steroids such as prednisone. Recent research has made ophthalmologists aware that elevated IOP does not always have to be present for glaucoma to start. In some, the IOP is normal, yet the optic nerve is clearly being damaged. In “normal pressure glaucoma,” the optic nerve’s own circulation may be faulty, as in chronic hypertension, aging, or hardening of the arteries, such that even a normal IOP can be too high. Elevated IOP is hardly ever painful, and the nerve damage can be so gradual that a person may not be aware. An eye exam, measuring the IOP and carefully studying the appearance of the optic nerve and looking for other risk factors, is the only way to detect the signs of glaucoma. Chemical agents in the form of eyedrops are the most frequently used treatment method, but in more difficult cases laser surgery or even a drainage operation to filter away the excess fluid from within the eye may be the only way to save vision. If you require treatment for glaucoma, your Eye MD will follow your IOP, check your visual field to be sure there is no progression of peripheral vision loss, and perform digital photography of the optic nerve and retina to record its appearance for later comparison, and adjust your therapy accordingly. Modern medical treatment for glaucoma has turned what was once a sentence of blindness to a disease that can be controlled in nearly everyone who is responsible enough to get their eyes examined and follow treatment recommendations. Call Eye MDs of Puget Sound today, and take the biggest step in preserving your own eyesight, by scheduling your own eye examination.
Macular Degeneration - Lining the inside of the eye is the retina is the thin sheet of nervous tissue that holds the rods and cones that actually “see.” In the very center of the retina is a specialized area called the macula. Here the rods and cones are most dense and numerous, and therefore provide the sharpest vision. It is the macula that sees fine detail such as print when we read, or helps to distinguish fine features in faces or objects. Any disease which disturbs the macula can interfere greatly with reading function. Thus it is that age-related macular degeneration (AMD), the leading cause of vision loss in our senior citizens today, is of such huge concern. Please be reassured that AMD causes a print or reading handicap, but not total blindness. AMD is now thought to be hereditary, a gene defect that manifests itself as a premature “wearing out” of the center of the retina.
Macular degeneration is classified as “dry” or “wet.” In its early stages, dry AMD involves gradual atrophy or “wearing out” of the pigmentary layer beneath the macula. Macular waste products build up and form yellow deposits called drusen, and pigment cells disperse and migrate. Gradually the vision begins to decline, and vision loss is usually mild to moderate. But given time, many with dry AMD will transition to a more aggressive form called wet AMD. Tiny abnormal blood vessels sprout up beneath the macula. These vessels leak plasma and blood, rapidly damaging the rods and cones of the macula. If not treated promptly, scarring will occur beneath the macula. Vision loss can be severe and permanent. Those found to have the characteristic signs of dry AMD will be counseled to take steps to minimize their risk of getting wet AMD, and to self-test their eyesight to pick up early signs of vision distortion that herald its early onset. Cigarette smoke increases wet AMD by as much as 33%, and many feel that unprotected exposure to harmful UV light can be damaging. Patients with AMD can still enjoy golf, gardening, walks and boating, but should protect their eyes with UV blocking dark glasses and a hat with a brim or visor. Also, patients should test each eye separately for the appearance of a small zone of visual distortion or blurring showing up near their central line of sight. This test is best done on a lined card called an Amsler grid. The technique of self testing will be demonstrated at Eye MDs of Puget Sound, and a complimentary Amsler chart is provided to our patients. If the patient detects a visual distortion, the classic symptom of wet AMD, the retina should be examined immediately.
Recent advances in treatment for wet AMD give your Eye MD the chance to eliminate the abnormal blood vessels. If caught sufficiently early, before much bleeding has occurred, vision can be stabilized and in some cases even restored. The use of newer lasers, photosensitizing dyes, and now the use of injectable agents discovered as an offshoot of cancer research comprise just some of the options available.
Unfortunately, there is no blood test that will allow us to predict whether a person will develop AMD. Macular degeneration can only be detected by examination of the retina. You can call Eye MDS of Puget Sound to schedule your own eye examination to determine whether your eyes are showing the early signs of AMD, especially if you are over 65, or have AMD in your own older family members.
Conjunctivitis (Pink Eye) - The delicate membrane that lines the inner eyelids and surface of the eye is called the conjunctiva. Inflammation of the conjunctiva causes reddening (conjunctivitis). It is most commonly caused by viral infection, but can also occur from bacterial infection, allergy, or dry eye, and can be mimicked by more serious internal eye inflammation. The treatment of conjunctivitis requires a visit to the doctor to properly diagnose the cause. The most common pink eye is viral conjunctivitis, usually painless, creating a mild mattery discharge, and often associated with other viral cold symptoms such as fever, stuffy nose, cough and sore throat. Viral pink eye is contagious and will require a child to stay at home from school or day care, an adult to be careful to wash hands. If mild, no treatment is required and like a cold, the body will fight off the virus in a few days. If more severe, or due to bacterial infection, an antibiotic eye drop is prescribed. If allergic, there is usually itching, with stringy discharge and more boggy swelling of the conjunctiva, and antihistamine eyedrops are prescribed. If due to dry eye, there are specific therapies which you can review in the Dry Eye section. Call Eye MDS of Puget Sound if you experience symptoms of conjunctivitis. Our trained staff will promptly get you in to see one of our board certified ophthalmologists for your evaluation.
Watery Eyes - One of the most common complaints we see in the office is watery eyes, a sometimes easy, other times very difficult condition to diagnose and treat. Watery eyes can be mild, or if chronic and persistent, can so irritate and blur that the patient is miserable. There are multiple causes of watery eyes. Watery eyes are normal when we cry, or when the eye is irritated by a cold wind (walking outdoors on a cold day), bright sunshine, allergy, air pollution or fumes, or even eye strain. A person without proper eyeglasses may present not as blurry eyes, but as watery eyes due to eye strain.
There is a balance between the rate at which we produce tears and the rate at which they are drained from the eye. Generally, our tear drainage ducts are adequate to remove tears so that our vision is kept clear. But excess tear production can overwhelm the tear ducts and cause flooding and watering. In addition to the normal causes of tearing listed above, irritation of the cornea will cause reflex tearing. A scratched eye, a foreign particle, UV flash burn, exposure from poor blinking or improper eyelid closure (common in aging), or even dry eye can result in overproduction of tears to the point that they overflow the tear ducts and pool (see under Corneal Diseases and Dry Eye above).
Watery eyes can also be caused by blockage of the tear duct drainage system. Normally, tears are pumped from the eye as we blink and directed into nasal passages via the tear duct. This is why our nose runs when we cry. In some, blinking is paralyzed by stroke, Bell’s palsy, or after botox. In older individuals, sagging facial features may cause the eyelids to fall away from the eye (ectropion), or injury may scar the eyelids, thus preventing tears from reaching the duct. In small infants, tearing may be due to a blocked tear duct, which generally clears on its own, but may require a simple probing to open the passage. The tear duct may be blocked by the swelling that occurs in allergy or infection, often responding to antibiotic or allergy eyedrops. But if blocked by scarring, narrowing, mucous plug, stone or tumor (rare), surgery may be required. A simple irrigation of the duct that can be done in the office may clear a stone or mucous plug, but in some an entirely new tear duct must be reconstructed if there is any hope at relieving the patient of symptoms. Seeing an Eye MD to properly diagnose the cause of watering is essential in treatment success.
The Complete Eye Examination - Having the eyes periodically checked by your ophthalmologist (Eye MD) will help preserve your precious eyesight. Children’s eyes should be examined at birth by their pediatrician and vision measured at age 3 1/2 to 4 years to rule out crossed eye or lazy eye (amblyopia), present in as many as 3% of the population. Visual acuity screening should be tested annually through the middle school years. Even if prior screening by the pediatrician is normal, we recommend children see the eye doctor for their first formal eye exam at approximately age 6 years (starting 1st grade), and every three years thereafter, as long as the pediatrician tests acuity yearly in the interim. Eye exams should be yearly for children who require eyeglasses, due to rapid changes often seen in young people. Young adults with healthy eyes may go longer between exams, but older individuals (over age 45) will require eye exams at least every two years as the eyes age, lose their reading focus, and later begin to develop the often seen problems of cataract, glaucoma, macular degeneration, and other disorders. Diabetics and others with “at risk” eyes will require more frequent follow up.
A proper eye exam does not just test you for eyeglasses. Carefully understanding your entire medical history, your medications, allergies, prior surgeries, and current medical problems are essential in understanding and helping you preserve your eye health. Your visual acuity is tested to determine whether it is clear or blurry and a refraction performed to determine whether you are focused properly. Your peripheral field of vision is tested. Your eye pressure is checked (glaucoma screening), a test done with a tonometer after your eye is anesthetized briefly with an eye drop. Your tracking accuracy and eye alignment is observed. Your pupillary reactions are observed. Your eyes are inspected at the microscope for eyelid and corneal health, and to judge cataract. Your eyes are examined internally with the ophthalmoscope to evaluate the retina, macula and optic nerve. For best evaluation, this latter step usually requires dilated pupils, using another eye drop. Once your evaluation is complete, a discussion of the results is undertaken, and any recommended treatment, follow-up, or glasses is prescribed. Dilating drops may cause your vision to be somewhat blurry for reading for several hours, and bright lights or sunshine may cause glare. Care in driving is recommended. Complimentary dark glasses are available from Eye MDs of Puget Sound for their patients.
Arranging your complete eye examination simple requires a phone call to speak to one of our receptionists. No referral is necessary, and Eye MDs of Puget Sound accepts most major insurances.
Your eyeglass prescription is taken to an optician or optometrist of your choice. For your convenience, Narrows Optical is located in our building. Affiliated with Eye MDs, our Optician Manager is Jeff LaFond. He and his assistants are experienced licensed opticians who can provide you with a wide range of fashionable eyewear, and lenses of superb optical quality (click Narrows Optical on the Home Page). If you feel there is any question, our ophthalmic technicians are happy to test your new eyeglasses to confirm their accuracy to the prescription. Your satisfaction is guaranteed at Narrows Optical.
