50 most common questions with answers in Eye Diseases

"Beauty is in the eye of the beholder" is a philosophical statement that can mean many things to many people. The beauty we can see directly with our eyes is less dependent on philosophy than it is on healthy eyes. In other words, sight is one of our most precious gifts. Much is being done to save our vision, and there is much we can do to help. One of the finest medical specialties is that of the ophthalmologist, and one of the most talented and compassionate is Dr. K. Michael Heslin.

Q. What is the major distinction between cataract and glaucoma? 

A. The word cataract is derived from the Greek; it actually means mist. It is the clouding of the substance of the focusing lens of the eye, which as it develops clouds or impairs vision. The development of cataracts is really a little bit like the graying of hair as the years go by. The human lens is actually a living organ that maintains itself with clarity through the years, and the development of a cataract represents a breakdown in certain aspects of the lens metabolism. This in turn leads to a change in the nature of the protein within the lens and to its subsequent clouding.

Q. Does the eye have its own metabolic system a smaller version, say, of the body's larger system? 

A. In a way, yes. All cells within the body have their own metabolic system, and, within the eye, every singular little area has a living cell with its own cell metabolism. The lens is no exception. It has a family of cells whose sole job is to utilize nutrients that maintain its clarity.

Q. Cataracts occur on the lenses of the eyes? 

A. No, actually it's within the substance of the lens. You can think of the eye almost like a camera. The clear front of the eye, which you look at when you look in the mirror, is really the front surface of the eye or cornea. As you look into the eye, you see the colored part or iris, which might be green, brown, or blue in different people. The black spot in the center is actually a hole through that iris, which we call the pupil. Right behind sits the lens, which is the strong focusing element of the eye. This is the area we're concerned with in the development of cataracts. As light passes through the lens, it is normally focused as an image onto the rear wall of the eye, which is known as the retina. From the retina, visual impulses travel by the optic nerve to the brain, where they are perceived and recognized by us as sight. The retinal layer in the back of the eye may be thought of as film in a camera, and the quality of vision is dependent on the health of that tissue. The optic nerve and the retinal tissue may be affected by circulatory diseases or by the disease known as glaucoma.

Q. What goes wrong with the metabolism or lens of the eye that causes it to become a cataract? 

A. Some of the things that go wrong are still somewhat of a mystery to researchers. Certain enzyme changes have been noted in the development of many cataracts, and there are, of course, many different types of cataracts. The final common denominator generally is a change in the nature of the lens protein itself, which can be determined in any number of ways.

Q. How many different types of cataracts are there 

A. There are many different cataracts, but they fall into several different groups. There are those that are congenital; people are born with them. And there are various types that develop as the years go by. As we discussed, a degree of cataract formation is almost as normal as the progressive whitening of hair, but in many people it's never significant enough to cause a visual problem.

Q. Are the end results of cataracts the same but the causes different? 

A. There are many different causes for cataracts, from trauma to radiation to some dietary influences. And cataracts themselves, when one examines the lens under magnification, are very different in appearance. For example, some are identifiable as problems related to diabetes or certain other types of singularly observable causes. The vast majority, however, fall into either a small and progressive yellowing or a frosting of the lens, which makes people slowly more nearsighted or susceptible to glare. Sometimes it is both. In both instances the overall vision decreases.

Q. Is there a connection between a form of nearsightedness and evolving cataracts? 

A. Of some sort in older people, yes. There was, in the past, a condition commonly called second sight, where people could throw away their reading glasses for a period of time. In effect, they were becoming nearsighted from the development of the cataract, and while their distance vision slowly blurred, their near vision would improve for a period of time. Eventually their near vision also dropped off.
Q. Do congenital cataracts suggest an inherited protein enzyme deficiency in the lens of the eye? 

A. In some instances, yes. Others are caused, as with rubella, by maternal infection during pregnancy. And one reversible cataract, the only known reversible cataract, is caused by a specific enzyme deficiency, which if noted right away can be reversed by changing the diet in infants.

Q. How is it ascertained that an infant has a cataract? When can you tell if the infant is seeing or not seeing? 

A. Generally, the first person to notice this is either the pediatrician, who routinely sees children before they leave the hospital, or a family member. One may notice that an eye turns inward or that the child doesn't follow a light or a face in front of him or her. And occasionally the cataract is quite dense. The black pupil in the center of the eye will look whitish instead.

Q. What is it about the passage of years that causes the major types of cataracts that affect the lens of the eye? 

A. The lens continually grows during life. Where most of our body systems reach full size and then maintain themselves at that size, the lens actually continues to elaborate fibers as it grows, and it should remain clear. However, the thing that occurs with the passage of time is a change in the nature of the protein itself, caused by a breakdown of the enzyme systems responsible for maintaining the protein in its very clear state. This process slowly leads to opacity within the lens, which at some point generally and rapidly progresses to a more white and visually obstructive nature.

Q. If one could stop the growth of the lens at some point in life, would we still develop cataracts? 

A. Yes, it would probably be impossible to stop the growth of the lens, because it is a living organ that requires nutrients to remain clear. If growth were to cease, the lens would in all certainty opacify from death of its cells.

Q. Is the growth pattern, then, a kind of perverted one past a certain age? 

A. Perverted, no. Inefficient, yes. The lens just stops functioning in a way that allows it to remain perfectly clear. However, there are certainly a number of patients in their late eighties or even late nineties, who have minimally impaired vision. They still have quite clear lenses with minimal cataract formation.

Q. Do we know why? 

A. No, at this point we don't. It is probably that dietary and especially genetic influences are predominant. Evidence is accumulating, however, that implicates exposure to high levels of ultraviolet radiation such as is found in heavy sun exposure.

Q. What is the usual age that determines the beginning stage of cataract growth? Or is it cumulative?

A. With a couple of exceptions, it is a slowly progressive process that may manifest itself by many different symptoms to an individual. People might, as we mentioned, find that their near vision seems to improve while their distance vision blurs somewhat. Alternatively, in another type of cataract, younger adults in their forties or fifties might notice a terrific amount of glare or problems early on with near vision. Often there is a feeling as if you had dirt on your car windshield while driving into the sun.

Q. What happens with glaucoma? How does this disease affect vision? 

A. The eye, just as the body, has an internal mechanism for maintaining a normal eye pressure. The eye constantly makes fluids that carry nutrients to its various components, including the lens, and it has in balance with this fluid production a drainage mechanism. As with blood pressure, this mechanism may go out of control. If you were to consider the eye similar to a bathtub, there's always water flowing in and water flowing out. If, at some point, the balancing mechanism of inflow and outflow is altered, the water level may start to rise in the bathtub. There is a similar situation in the eye when pressure rises. Elevated pressure then acts to push against the optic nerve in the rear part of the eye. Cumulative damage to the optic nerve, causing the death of nerve fibers, results in the loss of vision to the parts of the retina in the back of the eye, which those fibers serve. This is irreversible damage. Therefore, it's quite possible to develop this condition and have it progress for long periods of time with good overall vision before people are ever aware that their peripheral vision is deserting them. That's why glaucoma has been called the thief in the night. There is good reason for the pressure in a person's eyes to be checked approximately every year, at least after the age of 40, by a trained eye doctor.

Q. These periodic checks will determine if there is any progression toward glaucoma? 

A. That's correct. There is a normal range of pressure within the eye. While any pressure may cause glaucoma in a given individual, the ophthalmologist, through a combination of monitoring the pressure of the eye, measuring the visual field, and observing the state of health of the nerve itself, is able to determine whether a danger of actual glaucoma exists. He or she can then use appropriate treatment to control it.

Q. Glaucoma cannot be cured? 

A. Glaucoma can often be prevented or controlled. By not being cured, I mean that vision lost to glaucoma through the death of certain nerve fibers cannot be regained. The retina is a tract of the brain or central nervous system, and this material does not regenerate. Therefore, it's possible to arrest the damage at a given point, once discovered, in most instances. But it's not possible to regain what has been lost to glaucoma.

Q. The eye is made up of proteins, enzymes, and other nutritionally related systems. Would that mean we could find better nutrients to put into our bodies and in some way make our eyes healthier? 

A. That's a good question without a good answer. There is a good amount of research going on in this area, particularly with regard to the lens and the enzymes involved there. However, to my knowledge, there has not been identified to date any particular additive or nutrient within the diet that can have a particularly beneficial effect upon the eye outside the range of the normal diet and vitamin makeup.

Q. What known deficiency would accelerate eye disease? 

A. Low vitamin A, for example, commonly causes night blindness. However, most vitamins are connected with problems within the eye in the same way in which they would affect the general body. Vitamin C deficiencies, for example, which cause a number of connective tissue problems, can have the same type of effect on the connective tissue components of the eye. However, in this country we see very little, if any, of that.

Eye Diseases | 3 Common Eye Conditions



Q. What has been the conventional treatment for cataracts in order for one to be able to see again? 

A. A cataract has to be removed in order to make the line of sight clear once again. In the older conventional approach to this problem, a 180 degree incision in the eye is made. The eye is opened widely and the entire cataract affected lens is frozen and removed in one piece. The eye is then sutured up with a number of stitches, and the patient is restricted in activities during the period in which the eye heals. Following this, the patient must use either thick cataract glasses to replace the power of the lens removed or a contact lens. More recently, the development of artificial lens implants has become a third option for patients. Before the use of advanced microsurgical techniques, the procedure was very risky. In very experienced hands, the procedure is 99 percent successful.

Q. Contact lenses never seemed to work out for some people. 

A. That's very true. Much of this has to do with the fact that when you make a large incision, the healing process can occur irregularly and cause some scarring and a certain amount of astigmatism. In these cases, contact lenses won't work as well. In addition, in the older age group, many people have problems with dryness of the eyes. Contact lenses for them can be very difficult to manipulate. Therefore, we prefer ultrasonic emulsification and lens implants.

Q. How long does a procedure of that type take? 

A. That would vary depending on the expertise of the surgeon, but the operation might take anywhere from 20 minutes to 40 minutes.

Q. How long is the recuperative period? 

A. Generally, cataract patients can be kept in the office or hospital for a period of hours and then be at home or at work. They are minimally restricted in bending or normal activities. Eyeglasses are generally prescribed at about the second month.

Q. You are recognized for inventing computerized ultrasonic cataract surgery with the Heslin/Mackool Ocusystem. How would you describe the actual surgical steps? 

A. Quite simply, a tiny ultrasonic needle is placed in the eye, and the cataract is entirely removed through that puncture with the assistance of a sophisticated computer.

Q. Described in more primitive terms, the eye is punctured with a needle, and the cataract is broken up and sucked out? 

A. In a manner of speaking, yes.

Q. Once it's taken out, how do you put another lens back in? 

A. In my practice, we have dispensed pretty much with the thick cataract eyeglasses. We remove the cataract in that fashion and then either occasionally fit the patient with what is known as an extended wear contact lens (which is one that can be left in place for several weeks or months) or more usually place a very tiny type of artificial lens implant in through that opening and into the place where the cataractous lens was within the eye.

Q. So the cataract is aspirated out, and an artificial lens replaces it. Can the person then see as well as before the cataract? 

A. Successful cataract removal will allow the person to see as well as it is possible for him or her to see. This is ultimately determined primarily by the state of health of the retina and the optic nerve (the film in the camera), which we mentioned before. This can range from vision as good as what you and I now have to lesser amounts of vision as the years goby.

Q. Is it possible to have another operation if something goes wrong with the artificial lens implant? 

A. It's uncommon today for something to go wrong with the artificial lens over a period of time, because the lenses themselves are inert and apparently will last indefinitely. Things that might go wrong would have to do with other factors involved in the structural relationship of the lens to the eye or may have to do with other problems within the eye.

Q. With microsurgery, skilled surgeons can perform excellent operations. What makes the Heslin/Mackool Ocusystem particularly valuable for you in performing operations? 

A. When I first became involved in this area, it was apparent to me that this type of procedure phacoemulsification offered incredible benefits to the patient, in terms of both rehabilitation and comfort. It was also readily apparent to me that very few surgeons were skilled in its use. The reason, as I came to find out, was that machines were being designed by engineers without a precise point of view from that of a surgeon. Therefore, my goals in developing the Heslin/Mackool Ocusystem, from a surgical standpoint, were to increase the capabilities of surgeons already skilled in the use of microsurgical instrument procedures and to allow more surgeons to develop these skills so that the procedures would be more widespread. I believe that ultimately this will allow more patients throughout this country to benefit from this procedure, rather than only those patients served by a smaller number of surgeons.

Q. Why is my cataract operation being postponed for such a long time? I now have 20/70 vision in one eye and 20/50 in the other one, and I'm very unhappy, of course. My doctor says I'm not ready. Why would he say that? 

A. This is an interesting question because there once was a point in time when cataracts had to be what's known as ripe in order to be removed with a great deal of safety. At that point, the vision in such patients was tremendously reduced. With the techniques available today, cataracts no longer have to be ripe, and instead are usually removed at a point where the patient is unhappy with his or her vision. This presupposes that there are no other diseases in the eye that might lead one to defer surgery. For example, I recently operated on an orthopedic surgeon whose vision was 20/30. I have operated on a truck driver whose vision in a dark room was better still, but in sunlight he couldn't see a thing because of the glare. For these people, it was impossible for them to function (as it would be for myself) without the best possible vision. On the other hand, some people are very comfortable with vision of 20/70 or 20/100, and for these people, if they're comfortable and the cataract is not damaging the eye, then I see no reason for them to have surgery. Generally, a patient has a good enough idea when vision is decreased enough to want surgery. If your surgeon doesn't want to operate, it's very common to get two or three other opinions. Listen to them all.

Common Eye Problems



Q. One of my eyes is crossed, and I see double. My doctor does not want me to use this eye and is fitting a contact lens that will cover it. Is this called an occlusive lens, and what is your opinion?

A. That type of contact lens is used to blur the vision in an eye to a greater degree. This is one way to decrease double vision. There are many causes for this condition, and the treatment depends on the cause. Obviously, the choice is between seeing with one eye or seeing constantly double. Your surgeon can tell you if surgery would be possible in this case to develop binocular vision.

Q. What causes glaucoma after cataract surgery? 

A. Glaucoma, either after cataract surgery or without cataract surgery, is a malfunctioning of the pressure regulating mechanism within the eye, as was discussed earlier. There are rare types of glaucoma that are peculiar to complications related to surgery, but in most instances glaucoma after cataract surgery is related to the same mechanisms that occur whether surgery was performed or not. Generally, the treatment is the same for the two.

Q. What is the role of the orthoptist and the ophthalmic assistant? 

A. The ophthalmologist, as a medical doctor, is actually the head of an eye care team. This team is comprised of people who have varying degrees of training and/or certification in levels of eye care. This training may range from university degrees to extensive courses and clinical training. The orthoptist is a highly trained individual who has expertise in many areas of optics and ophthalmic care, particularly within the areas of eye muscle problems. They are really helpful specialists in that area, because few ophthalmologists limit themselves to subspecialization in that particular area.

Q. Is the orthoptist there for the patient or for the ophthalmologist? 

A. Both. Orthoptists are involved in patient care and diagnosis under the supervision of the ophthalmologist. They must have a formal degree from an accredited teaching program. For example, the New York Eye and Ear Infirmary is well known for this type of training. Orthoptists are highly trained technicians with very specialized skills that are useful for both ophthalmologists and patients.

Q. On a general basis, what are some obvious signs or symptoms of serious eye problems that should be checked as soon as possible? 

A. Signs include any pain, unexplained irritation, or redness of the eyes, anything out of the ordinary that calls your attention to the eyes or the eye area. Besides this, anything that causes clouding or blurring of vision, whether it's temporary or permanent, should be checked. There are, of course, countless symptoms, but any deviation from normal should be evaluated. It may be nothing, or it may be serious and time may be important. When in doubt, see an ophthalmologist. In addition, some serious problems give no symptoms until much irreversible damage has been done, so routine periodic examinations are important as well.

Q. How serious are signs such as double vision, fuzzy vision, and halos? 

A. Halos may mean high pressure in the eye, which may indicate an acute or chronic glaucoma. Blurry vision may mean anything from needing glasses to vascular disease, cataract, internal inflammation, and so on. In other words, it may mean anything from a benign, easily correctable optical problem to an illness that may reflect some serious bodily disorder primarily affecting the eyes.

Q. What do cobwebs, floaters, and flashes of light mean? 

A. Cobwebs are usually caused by the jellylike vitreous body inside the eye, which has separated away from and casts fine shadows onto the retina. It is not in itself a serious condition, but it should be checked because it may be associated with retinal disease, as flashing lights also may be. The lacy quality comes from seeing the shadows cast by the back of the vitreous body. Some may be large enough to be called floaters. If there are hundreds or thousands of tiny floaters seen as dust specks or smoke, it may mean a hemorrhage within the eye. Flickering lights may signal a retinal detachment or tear, or it may be of no consequence whatsoever. It might even be a vascular sign or a symptom that precedes a migraine headache. Interestingly, one doesn't have to get a migraine headache to have these symptoms, described as a migraine aura. These types of symptoms should be checked out by an ophthalmologist, because it is only by looking at the eye that we can see whether it's a benign or serious visual problem.

Q. What do tonometers measure, and what are the distinctions among the applanation tonometer, the Schiotz tonometer, and the airpuff tonometer? 

A. Tonometers are external ways of measuring the pressure inside the eye. This has particular significance for detecting glaucoma. With an applanation tonometer, a topical anesthetic is put into the eye. One notes a blue light. The tonometer actually comes against the eye and deforms the surface of the eye to a predetermined amount. By seeing how much force it takes to do that, one can determine the opposing force inside the eye quite accurately. The Schiotz technique is an older technique. It uses a silver metal plunger. An anesthetic is put on the eye, and one leans a weight on the eye. This deflects a scale, which in conjunction with a calibration chart allows one to correlate the deflection to the pressure. It is nowhere near as accurate as the other tests. It is affected by a number of things that may distort the values when compared to readings done by the other tests. The air puff tonometer is a noncontact means of measuring pressure. Its advantage is that nothing touches the eye directly, you don't have to put an anesthetic in the eye, and it doesn't require someone as skilled or as trained to perform it as the other tests do. It is quite accurate.

Q. As a patient, should I request any particular technique over any other? 

A. Modern offices and up to date physicians will be using an applanation, air puff, or similar electronic measuring means. I would not recommend the older Schiotz technique.

Q. How is ultrasound used in diagnosis or treatment? 

A. Ultrasound is used in both diagnosis and treatment of the eyes. In diagnosis, it is used to measure accurately lengths within the eye. This has great application for intraocular lens implants to replace cataracts. Another form of diagnostic use of ultrasound is very helpful in visualizing spatial relationships within the eye and in assisting in diagnosis when direct visualization is impossible, such as with dense cataract or hemorrhage.

Q. How is Fluorescein angiography used?

A. This is a test used to evaluate a number of primarily vascular conditions in the retinal and choroidal vasculature. A nontoxic dye is injected into a vein. It circulates through the body. Rapid photography is used to follow the dye sequentially through the little arterioles and then out through the veins. It provides a time lapse sequence to every aspect of the circulation in the back of the eye. As such, it can be used to identify diabetes, diabetic leakage problems, macular degeneration, and other problems. It assists in the proper use of appropriate laser treatment of such conditions.

Q. Are radioactive isotopes dangerous? 

A. All radioactive materials have their risks, as does the P32 isotope sometimes used in eye diagnosis. Generally, it is used only for specific diagnostic purposes, specifically when looking for malignant tumors such as melanomas. It's a means to an end for a serious condition. It is not used for other reasons.

Q. Are tumors common in eyes? 

A. Tumors are not that common, but they do occur. Some of the more common and serious ones occur in infants and young children.

Q. What is the significance when all of a sudden you find a red spot on the white of the eye? 

A. This is one of the things that very commonly occurs and frightens people because it is so dramatic. Generally, it's one of the most benign occurrences. It is a leakage from a capillary on the eye, and the bright red blood absorbs in about a week. It almost never has any significance. In some instances, it can be caused by strain, coughing, or elevated blood pressure. If it recurs or is associated with any other bleeding tendencies, have it checked.

Q. Can eyes get ulcers? 

A. Not in the sense of the stomach, but eyes do get ulcers on the corneal surface, for example. They may occur as part of several degenerative diseases of the cornea. They may also occur as a result of contact lenses if one has a poor fit or bacteria gets under the lens. The resulting infection may lead to an ulcerating abscess in the cornea.

Q. What causes a stye? 

A. Styes occur in the glands of the lid. There are 75 ducts and glands in each lid. When bacteria enter the ducts at the base of the lashes and travel down into the glands, the resulting infection is called a stye. Styes often occur in plepharitis, a chronic condition similar to dandruff of the eyelids. If one puts a lot of hot compresses on a stye immediately, more blood enters the area, which may enable the body to kill the bacteria. If that doesn't do the trick immediately, then an antibiotic in the form of drops or ointment will often be necessary. This is done under medical supervision. Sometimes a stye will need to be surgically opened and drained.

Q. What is the uvea? 

A. The uveal tract is one of the layers of the eye, part of which is the iris in the front of the eye. It is a very vascular network and is responsible for inflammations such as iritis in the front and uveitis in the back of the eye. All of these uveal tract infections and diseases are serious.

Q. What is keratitis? 

A. It is an inflammation of the cornea. It may have any number of causes, but the herpes virus is a major offender.

Q. What is Fuchs's dystrophy? 

A. This is a corneal dystrophy that comes about in later years and is named after the German ophthalmologist Ernst Fuchs. Basically, it is caused by the loss of the cells that maintain the clarity of the cornea. At a certain critical level, this will result in fluid from the inside of the eye creeping into the cornea and starting to cloud it. When that happens, of course, vision will drop. Often it is associated with developing cataracts. If vision is affected by advancing Fuchs's dystrophy, a corneal transplant ultimately is required to replace the diseased cornea with a new clear one.

Q. What types of eye disease benefit from laser surgery? 

A. Recently there has evolved a whole spectrum of lasers in ophthalmology. The original lasers are the argon lasers used for treating vascular diseases such as diabetes with heat. More recently, krypton lasers have been used for macular disease. The big excitement in the field today is something called the neodynium YAG laser. This is an extremely powerful laser that can be used to cut membranes within the eyes, secondary cataracts, and some problems in the vitreous area. It's a focused laser that creates a tremendous amount of energy instantaneously in a given area and acts just like a sharp knife. So, without actually cutting into the eye, you can obtain the same effects. It's only about a year and a half old and has become a very important treatment tool. At present, it is part of an ongoing national study in conjunction with the Food and Drug Administration.

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