Online Health Chat with Jeffrey Goshe, MD
August 20, 2012
Cleveland_Clinic_Host: Has injury, disease or certain medical conditions affected your cornea, making sight cloudy or difficult? The cornea is important to your vision. The cornea is the clear, dome-shaped outermost layer of the eye. Unlike most tissues in the body, the cornea contains no blood vessels to nourish or protect itself against infection, but receives nourishment from the tears and aqueous humor that fills the chamber behind it.
Corneal diseases and disorders can range from the routine to the complex, and include allergies, conjunctivitis (or pink eye), corneal infections and inflammation, dry eye, Fuchs’ dystrophy, corneal dystrophies, herpes zoster (shingles), iridocorneal endothelial syndrome and keratoconus.
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About the Speakers
Jeffrey Goshe, MD joined Cleveland Clinic Cole Eye Institute after completing a fellowship in cornea and external disease at Devers Eye Institute, in Portland, Ore. During his fellowship, Dr. Goshe trained with Mark A. Terry, MD, a world-renowned leader in cornea transplantation.
Dr. Goshe is actively researching corneal transplantation techniques and has published peer-reviewed journal articles on Descemet's stripping automated endothelial keratoplasty (DSAEK) and deep anterior lamellar keratoplasty (DALK). He completed his ophthalmology residency at Cole Eye Institute, where he was elected chief resident, served on the resident education committee, and won the Best Resident Paper/Presentation Award at the 2009 Cole Eye Institute Annual Research and Alumni Meeting. Dr. Goshe graduated from Case Western Reserve University School of Medicine, where he was inducted into Alpha Omega Alpha.
Cleveland_Clinic_Host: Welcome to our Online Health Chat with Cleveland Clinic specialist Dr. Jeffrey Goshe. We are thrilled to have him here today for this chat on Corneal and External Eye Diseases. Let’s begin with some of your questions.
shadow: What causes corneal keratopathy? What problems does this condition cause?
Dr__Goshe: Keratopathy is a very non-specific description for anything abnormal with the cornea. (It basically means "abnormality of the cornea.") Unfortunately, I can't give you any more specific information unless you can qualify the term in some way (e.g., "nodular keratopathy").
juniper: I was diagnosed with corneal erosion and had a bandage lens placed on the eye with one-week follow up to remove lens. I used Zymar® drops once a day while the bandage was on. I was told there was told there was a four- to six-week heal time. I am at the four-week mark. My eyes are scratchy, gritty, irritated and burning. My doctor says to just give it time. I use eye drops several times an hour still as well as ointment at night. Are my symptoms normal at this stage in the healing process? Am I making too much of the symptoms?
Dr__Goshe: If the eye is still symptomatic at this point, the erosion may not have healed completely or is still re-eroding from time to time. An examination with a cornea specialist is warranted at this time to determine what the cause of your symptoms is, and decide what further treatment should be offered.
juniper: What causes corneal erosion?
Dr__Goshe: Generally speaking, corneal erosions are the result of a poor adherence between the outermost layer of the cornea (the epithelium) and the tissue it attaches to (basement membrane). The most common causes of erosions are previous trauma (e.g., fingernail scratch or other cause of corneal abrasion) or an inherited condition called anterior basement membrane dystrophy (ABMD) which affects approximately 10% to 15% of the population. Most patients with ABMD do not experience corneal erosions, but for some it can be frequent and painful.
japike43: My ophthalmologist has told me that I have Fuchs' dystrophy. What suggestions do you have that I might deal with this and not allow it to worsen, or is that possible?
Dr__Goshe: Fuchs' dystrophy is not an uncommon condition. It affects the internal layer of the cornea—the clear part of the eye through which light passes as it enters the eye. Treatment is initially symptomatic, and may consist of observation or hypertonic (salt-based) ointments and drops to decrease the corneal swelling that Fuchs' causes. When the symptoms and vision have reached a point where the vision is affecting daily living with driving, reading, etc., surgery may be offered. The most common procedure for this is called DSAEK (Descemet's stripping automated endothelial keratoplasty) which is a partial cornea transplant. Often times, a cataract surgery is performed at the same time if your ophthalmologist thinks it is beneficial. In terms of future worsening, Fuchs' is typically a slowly progressive condition and does not cause permanent visual problems in a short period of time (even months to years). The only way to determine how advanced your Fuchs' is would be to have an examination with a cornea specialist.
Epithelial Basement Membrane Dystrophy
billt: I was diagnosed with epithelial basement membrane dystrophy. Is a corneal transplant the only form of treatment, or can something else be done? On television they were discussing a study that used stem cells for corneal regeneration to help regain vision. Would stem cells help with my type of condition?
Dr__Goshe: Epithelial basement membrane disease (EBMD) rarely requires any form of corneal transplantation unless there is some other significant corneal problem. These can include severe scarring, which is rarely related to EBMD, or a different problem with the cornea like Fuchs' dystrophy. Neither of these problems is typically related to stem-cell deficiency, so I don't think that stem cell therapy would have any benefit. The most common treatment for EBMD is epithelial debridement, or polishing the surface of the cornea by remove the abnormal tissue with a small blade in the operating room. The procedure is short and typically very effective for this purpose.
g20: Six months ago I had a cataract surgery. The surgeon also scraped a corneal keratopathy (though it never bothered me before). Now my vision is blurred, and I have a scratching feeling everyday so much that I need to keep this eye closed for relief. Before the surgery I felt the scratching sensation only once in a while. The surgeon told me it will never get better. I'm looking for a second opinion.
Dr__Goshe: Chronic irritation in this situation is very difficult to assess without examining your eyes. There are very few problems that cause surface irritation for which no treatment can be offered, so I wouldn't lose hope. The most likely causes would be recurrent erosions (spontaneous abrasions due to weak adhesions of the surface layer of the cornea), dry eye syndrome or other less common causes. I would be happy to take a look, and let you know what can be done.
Possible Corneal Problems with Glaucoma
lendin: I’ve had glaucoma since I was a baby, and use drops to control the pressure. But a few weeks ago, I started having blurry vision. My pressure is normal. I read online that the blur could be from scratches in the cornea and no specific treatment exists. Is this true? How do I fix this problem? Or will I always have blurry vision?
Dr__Goshe: Blurry vision in your situation could be due to a variety of different causes. Certainly, the most important issue is to determine with your glaucoma specialist that there is no visible progression of the optic nerve damage. Assuming that the glaucoma is under control and the nerve is not causing the change, there are still many other causes that could be evaluated as part of a full eye examination. If your problem is in fact arising from the cornea, treatment exists to improve or restore the vision. The treatment would depend entirely on what your ophthalmologist identified during the examination (dryness, corneal swelling, etc). I would definitely recommend seeing an ophthalmologist to determine the possible causes of your symptoms.
Corneal Scarring - Keratitis
cowtow: I got keratitis from my contacts. I have not worn contacts since. I was told there was corneal scarring due to the keratitis. How does an eye infection cause scarring? If I go back to wearing contacts, will that slow down healing of the scarring? Will the scarring ever go away?
Dr__Goshe: Keratitis in the setting of contact lens wear usually occurs as the result of a bacterial infection. When the cornea is infected, or inflamed even in the absence of true infection, white blood cells travel to the area and release enzymes that kill the bacteria, but also destroy some corneal tissue in the process. The end result, which typically is achieved within two to three months after an infection is treated, is a corneal scar that may affect the vision. Typically, these scars do not change much over time and will not likely improve after the first several months. Future contact lens wear does not affect the healing process at this point, but can be the cause of future infections. This can lead to more scarring or worse problems. Often times, if the scarring is affecting the vision, a hard contact lens can be fit to correct for any irregular astigmatism induced by the scar. Finally, for severe scars, the treatment is usually corneal transplantation, or in some cases for superficial scars, a laser procedure called phototherapeutic keratectomy (PTK).
hold_on: Without a physician telling you, is there any way to know if there is corneal scarring from a previous eye infection?
Dr__Goshe: Since the changes are best appreciated with a microscope, it would be difficult to tell without having an eye examination with an optometrist or ophthalmologist.
jerryk: I am 26 year old, and have worn contacts for over 10 years. Two months ago I developed a severe infection and corneal ulcer. I now have a small corneal scar in my line of vision. My vision in the affected eye is 20/40 with glasses. I experience halos, floaters, foggy vision (particularly in bright light) and blurring. My eye doctor then said that while there may be some improvement to the scarring in the coming months or years, I'll always have vision problems. He said he wouldn't consider performing PRK (photorefractive keratectomy) or similar on that eye. I am now seeing another physician who seems more optimistic. He indicated that he expects significant improvement. He's treating me with fluorometholone 0.01% twice per day and Maxitrol® ointment at night. I understand that no one can predict exactly how or whether I'll heal; I just have to be patient. How do you know which doctor to trust? That said, I have the following questions:
Is there any benefit (or even potential benefit) to taking Vitamin C? I've read online that some doctors recommend 1000 mg/day to prevent and/or heal corneal scarring. Is it dangerous or worth a try?
My vision in the affected eye is unstable. Throughout the day it's generally blurry when trying to read, but there are times when it's significantly sharper. There doesn't seem to be any pattern to this—it's not related to taking my eye drops, time of day, lighting or anything else as far as I can tell. What's causing this? Are vision fluctuations a part of the healing process?
The ophthalmologist said I could start wearing contacts soon. He said there's always some risk to using contact lenses, but seemed to think I could (and should) use them. I'm considering it because I've always had better vision with contacts than glasses. Am I at an increased risk of future infections or scarring now that I have had a corneal scar?
I'm on the computer all day at work. Can that interfere with healing?
Dr__Goshe: To address the specific questions, first, vitamin C in high doses (although it is difficult to quantify) has been shown to have some beneficial effects with corneal surface healing in the acute phase of a serious corneal ulcer/infection. The vitamin C may inhibit certain enzymes that cause destruction ("melting") of the cornea in these severe situations. Some practitioners debate the efficacy of this treatment, and I would say that it is not routinely used as an adjunct to treatment of corneal infections except with a very severe "corneal melt." Taking it at this point is probably not likely to alter your condition either positively or negatively.
The central location of your scar certainly explains your visual symptoms. Your best bet may be to try being fit with a hard contact lens (rigid gas permeable) which masks irregular astigmatism, the most common cause of visual symptoms in patients with similar issues as yourself. A laser PRK or PTK (phototherapeutic keratectomy) procedure could be performed if your corneal scar was superficial enough, and depending on the overall thickness of your cornea.
Contact lens wear after an infection is not out of the question, although I worry about the possibility of future infections. Namely, you must stop anything that raised your risk (e.g., sleeping with the lenses in, or not changing the lenses as often as recommended).
Hard lenses carry a much lower risk for infection and may help more with the vision as described above. The other option is to use a daily disposable soft lens which is more expensive, but less likely to cause infection.
As far as your question about which doctors you can trust, it is difficult to answer. I think for your situation, I would definitely recommend seeing a cornea specialist (a person who has completed fellowship training in corneal disease).
klupto: What is a corneal transplant? How will it help my eyesight?
Dr__Goshe: A cornea transplant refers to a surgical procedure during which a portion of the clear part of the eye (the cornea) is removed and replaced with either a donor cornea (from a person who had a healthy cornea who passed away and donated their organs) or, in rare cases, a synthetic cornea. There are a variety of reasons for which this treatment may be offered. The primary reasons are to remove opacities and scars of the cornea, and replace them with a clear ‘window’ into the eye. It is difficult to say for your individual situation unless I had more information regarding your condition.
come_back: I had cataract surgery years ago, and have clouding of the eye. My physician said a corneal transplant might help. How successful are corneal transplants? How will I know if it will work for me? I am afraid to have another eye surgery if it’s not going to help.
Dr__Goshe: The most common cause of clouding of the eye after cataract surgery is termed ‘pseudophakic bullous keratopathy,’ which refers to the gradual loss of the internal cells of the cornea as a result of cataract surgery and normal aging. If the rest of the eye is healthy (meaning the retina and the optic nerve) and the cataract surgery was uncomplicated, the surgery to repair the cornea is typically very successful (with a success rate greater than 95%) for treating the problem that you are likely describing. Other factors (complicated cataract surgery with damage to other structures inside the eye) may make the surgery more challenging, but it is still generally very successful. The surgery for this problem is typically a partial thickness transplant (DSAEK, Descemet's stripping automated endothelial keratoplasty) which allows for visual recovery over a matter of four to six weeks. A full examination would need to be performed to determine how successful the surgery would likely be in terms of improving your vision.
prettyp: I was told that I have holes in my cornea. Is there a name for this condition? I was being treated with drops, but my doctor told me she wants to do a contact patch because the drops aren’t working. What is this, and is this a recommended approach to my condition?
Dr__Goshe: It is hard to say what your doctor was trying to describe. I would guess that they were referring to surface irritation (most commonly due to dry eye). I would need more information or an examination to better assist you with this problem.
orangey: Can untreated dry eyes cause vision problems?
Dr__Goshe: Generally, dry eyes do not lead to significant long-term visual problems and are treated symptomatically, i.e., to provide relief of the irritation rather than to prevent a worsening problem. However, there are some situations in which severe dry eye syndrome can predispose patients to abrasions, infections and scarring, which require aggressive topical lubricants. Your ophthalmologist would have to determine how severe your corneal dryness is to decide how aggressive the treatment should be.
temple: What causes dry eyes? I am 44 years old, and only started to have dry eyes about eight months ago.
Dr__Goshe: The cause of dry eyes is not well understood, except to say that many factors are involved. The most common risk factors are increasing age, female gender, and, less commonly, a variety of inflammatory and autoimmune conditions that can affect the tear glands (for example, in patients with rheumatoid arthritis). In women, there appears to be a role in the hormonal changes that occur between the ages of 40 to 50 years old as dry eye syndrome often develops in the perimenopausal age group. Also, certain medications are known to cause worsening dry eyes by affecting the chemical pathways that stimulate tear production, most commonly antihistamines, antidepressants and some diuretics.
temple: When drops don’t work, what is the next step in treatment of dry eyes?
Dr__Goshe: It's difficult to say without examining your eyes, as there are many factors that contribute to dry eyes. First of all, your doctor should assess your eyelid margin oil glands (Meibomian glands) to determine if they are flowing properly as this may exacerbate dryness and evaporative tear loss in many patients. The frequency of the drops often may need to be increased. Typically, patients are started on artificial tears four times daily. If this is not sufficient, I generally have patients change to preservative-free artificial tears. They come in vials, not bottles, and are over-the-counter, and increase up to hourly usage. The next step may be placing punctal plugs, i.e. small silicone caps that slow the escape of tears away from the eyes. Some practitioners also will prescribe Restasis®, a medication that has been shown to increase tear production for patients with mild-to-moderate dry eye syndrome.
Allergies of the Cornea
martin2: What allergies affect the cornea? What can be done to prevent this damage?
Dr__Goshe: Anything that causes allergic symptoms elsewhere in the body (environmental allergens, pet dander, medications and dust) can produce ocular symptoms. The cornea is not typically affected directly as it has few white blood cells that release histamine. The major tissues affected in the eyes are the inside surfaces of the lids and the clear tissue that coats the white of the eye (the conjunctiva). For most people, this causes itching and burning which are best treated with oral Zyrtec® or Allegra®, or topical antihistamines (e.g., Zaditor® or Patanol®). Except in very severe circumstances, this rarely causes permanent damage.
clatter: Is it possible to be allergic to contact lenses or rather what they are made of?
Dr__Goshe: Yes, in a way. The reaction that people get is typically called "giant papillary conjunctivitis" and may be caused by the proteins that build up on certain lens materials, or even just the mechanical friction of the lens rubbing against the inner surface of the lids. In many cases, this can be treated by changing the type of lens material with the help of an optometrist or taking a break from wearing the lenses for one to two weeks.
Shingles of the Eye
work_on_it: What is the connection between shingles and the eye?
Dr__Goshe: Shingles can affect the nerve that innervates the eye and forehead (the trigeminal nerve). It is one of the more common locations for shingles to manifest. In some cases of facial and forehead shingles, probably 10% to 20% or less, the virus can affect the cornea or other structures inside the eye and require treatment by an ophthalmologist.
stellarp: How does one get ocular herpes?
Dr__Goshe: Two different types of herpes viruses can affect the eye, herpes simplex (the virus that causes cold sores and fever blisters) and varicella zoster (the virus that causes chickenpox and shingles). When herpes affects the eye, this is not generally thought of a sexually transmitted infection as the virus is so commonplace (herpes simplex type 1) that some people have estimated that approximately 75% to 90% of adults carry this virus in their system.
It is likely passed the same way that cold sores are passed, namely contact with infected secretions (saliva, tears, etc.) Infected genital secretions can also carry this virus (typically caused by HSV type 2), but this is a less common cause of eye manifestations. Herpes infections of the eye are often re-activation infections, meaning that the original exposure may have happened years or even decades before the symptoms manifest. These infections, like cold sores, have a way of appearing, often during times of stress, and then disappearing for long periods of time before re-activating. There is no cure to these viruses, so that we are always vulnerable to re-infection once we carry them.
FloatersTTMeehan: I have an image in my eyes, something like the outline of a fish (really), which has always been there. What could this be?
Dr__Goshe: That sounds more like a vitreous floater (you can Google "posterior vitreous detachment", the most common cause of floaters). If this is a new symptom in the past month you should have a dilated eye examination in the near future to assess if there is anything that needs to be done.
Cleveland_Clinic_Host: I'm sorry to say that our time with Cleveland Clinic cornea eye specialist Jeffrey Goshe, MD is now over. Thank you Dr. Goshe for taking the time to answer our questions today about corneal and external eye diseases.
Dr__Goshe: Thank you for all of your questions.
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