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Keeping an Eye on Your Vision - Comprehensive Ophthalmology

Online Health Chat with Dr. Richard Gans

January 19, 2011


Introduction

Cleveland_Clinic_Host: As we go through life, many people experience vision changes - from refractive issues to eye diseases. The key to healthy eyes is early diagnosis and treatment of ophthalmic conditions.

Dr. Richard Gans joined Cleveland Clinic Cole Eye Institute in 2004. He is a comprehensive ophthalmologist with specialty interests in cataracts, glaucoma, and diabetes. He is also an accomplished surgeon. In addition to his clinical practice, Dr. Gans is an Assistant Professor with the Department of Ophthalmology at The Lerner College of Medicine of Case Western Reserve University in Cleveland.

Dr. Gans has been an ophthalmologist in the Cleveland area for more than 20 years. Prior to his coming to Cleveland Clinic, he was on staff at University Hospitals of Cleveland and at the Mt. Sinai Medical Center in Cleveland. Dr. Gans is a graduate of Case Western Reserve University School of Medicine in Cleveland. He also completed his ophthalmology residency at Case Western Reserve University.

Cleveland Clinic’s Cole Eye Institute is ranked among the top 10 ophthalmology programs in the country by U.S .News & World Report, making it the top-ranked program in Ohio. We are among an elite group of dedicated, comprehensive eye institutes. Our fully integrated model helps us provide patients with quick and easy access to specialty and subspecialty care for a wide spectrum of eye conditions – from the routine to the complex. Cole Eye Institute has extended its quality ophthalmic care to several locations throughout Northeast Ohio, providing patients with access to ophthalmologists closer to their homes.

To make an appointment with Dr. Gans or any of the other specialists at the Cole Eye Institute, please call 216.444.2020 or call toll-free at 800.223.2273, ext. 42020. You can also visit us online at www.clevelandclinic.org/eye.

Cleveland_Clinic_Host: Welcome to our Online Health Chat with Dr. Richard Gans. We are thrilled to have him here today for this chat. Let’s begin with the questions.


Cataracts

clubber: I have to have cataract surgery on my left eye. When can I expect to be able to see out of that eye again after surgery?

Dr__Richard_Gans: Most of my cataract surgery patients start to notice improvement in their vision within 24 hours of surgery. Typically, the eye is said to be healed and the vision stable after four weeks. During that healing time, however, patients have usually returned to their normal routines with better vision and almost no restrictions to their activities.

independent: How do I know when I'm ready for cataract surgery?

Dr__Richard_Gans: There is no critical time - from a medical point of view - when cataracts need to be removed. Ophthalmologists have the technology to remove cataracts at any stage in their development. The real time to have a cataract removed is when the cataract limits your vision in such a way that it impairs your ability to function on a daily basis. Typical reasons for having cataracts removed include the inability to see to drive at night, difficulty reading small print, excessive glare, and needing extra light to see.

JoeB: Is cataract surgery possible after one has had LASIK? I heard it is difficult?

Dr__Richard_Gans: Yes. Cataract surgery is possible after LASIK. I am called upon to do it, frequently. The problem with cataract surgery after LASIK is in trying to calculate the power of the lens implant to place in the eye at the time of the cataract operation. After LASIK, those determinations are much more challenging and inherently less precise.

please_thanks: I am nearsighted and have astigmatism. My eye doctor tells me that I need cataract surgery, too. Can my nearsightedness and astigmatism be corrected at the same time as my cataract?

Dr__Richard_Gans: Yes. Traditionally, the lens implants used during cataract surgery could correct nearsightedness or farsightedness. Now, there are premium lens implants that can correct the astigmatism, as well.

Melinda: My mother is in her mid-70s and was just diagnosed with cataracts. She was told that the treatment is a surgical procedure Is surgery the only treatment option for cataracts? If she has to have surgery, what is a typical recovery time?

Dr__Richard_Gans: Surgery is the only treatment for cataracts. A cataract is the natural lens of the eye that has lost its clarity. To restore vision, the cloudy lens has to be surgically removed from the eye, and is usually replaced by an artificial lens that is implanted in the eye at the same time. If there is no other associated trouble within the eye, the vision usually improves very rapidly, starting within the first 24 hours. Although it is four weeks before the eye is fully healed, the vast majority of people are back to their normal routines and seeing better right away.

cleancut: My retina specialist tells me that I need to have my cataract removed before she can fix my retina problem. Is there any way that I can avoid having two operations?

Dr__Richard_Gans: At the Cleveland Clinic Cole Eye Institute, we have specialists in all areas of eye care. When situations such as this arise, our surgeons can work together in our own operating rooms to do both operations at the same time, saving you a second trip to the operating room.


Floaters

Sandra: I see dark shadow-like figures when I’m in a bright room. They seem to shoot across my vision. I was told that these are called floaters. I have had them for a couple of years now. Should I be concerned?

Dr__Richard_Gans: Many floaters are nothing more than a nuisance. Some floaters, however, can be a sign of serious problems within the eye. Anytime new floaters develop, particularly if they are associated with flashes of light in your field of vision, they should be investigated right away by an ophthalmologist. Floaters are symptoms that can be associated with retinal detachments or bleeding within the eye.

JZImaging: I have floaters, but the one in my right eye looks like a string with other strings hanging off it. It seems like - over the last few years - it has grown and has gotten more strings or legs coming off it. Is it possible for a floater to grow? Should I be concerned? It blocks the whole eye vision and makes everything blurry. I am only 44 years old and am concerned that I one day may not pass my driving test since glasses cannot fix the blurry vision.

Dr__Richard_Gans: In general, floaters don't grow. They do, however, move within the eye. As they move forward or backward, they can appear larger or smaller. Regardless, if the floater is impairing your vision or is changing, you should be examined by a retina specialist to make certain there isn't any other pathology within your eye. In addition to routine floaters, bleeding within the eye can appear to be a floater that changes in size and shape.


Macular Degeneration

hudsonrose: My mother-in-law is 90 and has macular degeneration, as does her 80-year-old brother. I have read about the stem cell implantations being done in England that are curing it. How long do you foresee before this procedure is available here in the States, and is it the miracle cure they describe?

Dr__Richard_Gans: I am not aware of any evidence that stem cell transplantation has a significant bearing on the visual outcomes for patients with macular degeneration. Stem cell transplantation is used for corneal disorders.

jackspr: Are Lutein and zeaxanthin a waste as preventers for a 75-year-old?

Dr__Richard_Gans: The jury is still out on that question. There is currently an NIH study (AREDS2) that will hopefully answer that question when it is published. For now, the only formal recommendation is the original AREDS formula for people who are at high risk for macular degeneration.

Anxious: Any way to prevent macular degeneration?

Dr__Richard_Gans: Unfortunately no. There are risk factors that you can control. Smoking is a major risk factor for macular degeneration, so don't smoke. Ultraviolet light is a risk factor as well. When outside, it is a good idea to wear sunglasses to protect you from UV exposure. In addition, routine eye examinations will be able to tell you if you are at risk or if you need any treatment.

Ted: I have been told that I have something called drusen in my eyes. How serious is this?

Dr__Richard_Gans: Drusen are yellowish spots within the retina that are warning signs that you could be at risk for developing a problem with macular degeneration. Drusen, by themselves, usually do not cause visual symptoms. If macular degeneration develops, however, vision can be impaired. People with drusen are advised to do self-testing at home to make certain they discover symptoms of macular degeneration, if they should develop.

The good news is that our ability to treat macular degeneration is much better now than ever before. Some of the foremost experts in treating macular degeneration and those who were instrumental in researching the new drugs for the condition are right here at the Cole Eye Institute of Cleveland Clinic.


Dry Eyes

bowserc: I am 55 with glasses, have had dry eye issues with contacts in the past and don't know what kind of surgery would be available.

Dr__Richard_Gans: Refractive surgery might be able to limit your need for glasses. Dry eye problems, however - if severe - might be a reason not to have refractive surgery, as the symptoms can sometimes be worse afterward. There are numerous treatments for dry eyes that might alleviate your symptoms and make you a better candidate for refractive surgery.

comedy: I have dry eyes. They feel like I have sand in them, and are usually itchy and red by the end of the day. I have tried over-the-counter artificial tears, but they don’t seem to be working, Any suggestions?

Dr__Richard_Gans: There are multiple types of over-the-counter artificial tear supplements. You may want to try another. If you have no relief, there are other options. There is a prescription eye drop that can help to promote tear production. Tiny plugs can be placed in the tear ducts to help keep the tears in your eye longer. Using a humidifier in your home can help, too. Finally, taking oral omega-3 fatty acids, such as fish oil supplements, can sometimes help to relieve dry eye symptoms.


Contact Lenses

hudsonrose: Are they any new advances in contact lens, and do you recommend usage of the no-rub formulas, and are they as effective?

Dr__Richard_Gans: It has been a few years since I have prescribed contact lenses. We have multiple ophthalmologists and optometrists at the Cole Eye Institute that would be better equipped to answer such a question.

nystrom: Are there bifocal contact lens out yet for people with astigmatism?

Dr__Richard_Gans: Yes. There are bifocal contact lenses. Unfortunately, not everyone who tries them finds that their vision is adequate to meet their needs. It is physically difficult to get a variable correction for multiple focal distances into a soft plastic that drapes over the eye.

Insider: I wear contacts for working at the computer and everyday activities, but for general reading I wear regular glasses. When wearing my contacts, I often suffer from the lenses drying out, especially in air conditioned or heated rooms. I am constantly using drops. Is there ever a point of overuse with possible damage to the eyes?

Dr__Richard_Gans: Most lubricating drops do not harm the eye. However, if you are using them more than six to eight times per day, the preservative in the bottle can irritate your eyes. If you are using the drops more than six to eight times per day, you might want to switch to non-preserved lubricants. Also, remember that any drops can get contaminated once they are left open. Only use fresh drops when putting them in your eyes.

If your eyes get uncomfortable while wearing contact lenses, make certain to remove them ASAP. Serious, potentially vision-threatening infections can develop rapidly in contact lens wearers.

JoeB: What is your opinion of scleral contact lenses?

Dr__Richard_Gans: Again, not my area of expertise, but scleral contact lenses do have utility in some pathologic conditions of the eye.


Other Eye Conditions

GZ: I have been diagnosed with epithelial basement membrane dystrophy (EBMD), which has progressed in one eye to the point that lenses can't seem to correct for clear vision. Short of corneal transplant, are there any alternative treatments? I recently saw a story on TV that talked about a study using stem cells for corneal regeneration to help the sight-impaired regain vision. Any hope for the future for those with EBMD?

Dr__Richard_Gans: Epithelial basement membrane dystrophy is a common, congenital, corneal condition that can cause recurring, painful erosion of the surface cell layer of the eye, as well as diminished vision. There are a number of treatment modalities to prevent and/or treat these occurrences.

For the painful erosions, ocular lubricants or hypertonic solutions can prevent recurrences. When this fails, a superficial keratectomy - surgically scraping off the surface cell layers and allowing them to grow back - will oftentimes alleviate symptoms. If this should fail to prevent new symptoms, there are other surgical options. In addition, the EXCIMER laser, the laser used to perform LASIK, can sometimes be used in a therapeutic mode to treat this condition.

For the diminished vision from corneal surface irregularity, superficial keratectomy or EXCIMER laser phototherapeutic keratectomy (PTK) is often useful. Although corneal transplantation is possible and very successful, it would be very unlikely that someone would require a corneal transplant just for this dystrophy.

plaything2: I have had conjunctivitis a few times in the past year. My doctor told me that it was not due to bacteria so no antibiotics were prescribed. I am wondering what tips you can provide to help relieve the symptoms if it comes back again?

Dr__Richard_Gans: Other causes of conjunctivitis include a virus, an irritating substance, and allergies. Only the bacterial form is treated with antibiotics. To relieve symptoms, make sure to remove contact lenses and wear glasses until the inflammation subsides, place cold compresses on your eyes, use baby shampoo, rinse your face and eyelids, and remove any substance causing the irritation.

johnnnita: My mother had an "ocular vein occlusion," which led to near blindness in one eye. Can you tell me what this is and if I (her son) should be concerned about inheriting this condition. Both my mother and I have worn corrective lenses. I have had astigmatism since an early age. I also have "floaters" and random episodes of double vision left to right. The episodes have no calculated frequency. During episodes, which last about one to two minutes, I can close one eye or the other and my vision is fine. Otherwise, my vision is fine. There is no pain with the episodes. Can any of this have anything to do with my mother's occlusion? I have had this checked, and I'm told my symptoms are probably migraine-related (silent migraines). Please provide any additional insight (pardon the pun).

Dr__Richard_Gans: A retinal vein occlusion is a problem in which the circulation in the retina is blocked. It is oftentimes associated with high blood pressure. Other vascular diseases can predispose a person to vein occlusions as well. Although it doesn't sound as though your symptoms would predispose you to that type of condition, it sounds as though you ought to have a full eye examination to determine the cause of your symptoms.

JoeB: Hello, I had LASIK in 1999 and an enhancement in 2000. My vision was great until 2008. Since then, I have been bothered by glare, star bursts, and halos. My indoor and night vision is terrible and negatively affects my daily life. I use Alphagan P and SynergEyes contact lenses, and sometimes glasses to help. I do not need reading glasses and I am 47 years old. Any suggestions are welcomed. I have seen several MDs and ODs and get different diagnoses, and I am very reluctant to get more surgery, but will if I know it will help. I also want to know why no one has developed a safe and effective pupil constricting eye drop for these problems.

Dr__Richard_Gans: Although people can occasionally have visual symptoms such as yours after refractive surgery, it sounds as though your symptoms developed at least eight years later. If this is the case, there may be another cause of the glare, starbursts, and halos. Early cataracts and other media capacities within the eye can give similar symptoms. My best suggestion would be to get a full examination by an ophthalmologist experienced with these issues to help find a solution.

jelly: Suddenly, black spots and flashes appear. What is this? What can I do?

Dr__Richard_Gans: Anyone who develops black dots or flashes of light in their field of vision should be evaluated right away by a qualified ophthalmologist. These can be signs of a process called a posterior vitreous separation, a normal maturation change within the eye that has a risk of an associated retinal tear that could cause a retinal detachment.

JZImaging: In the white area of my eyes I get bumps that make it feel like sand in my eyes. My
eye doctor years ago said it was sinus drainage and gave me eye drops. Is this true and is this normal? It is in just in my left eye.

Dr__Richard_Gans: The most common "bumps" on the white part of the eye are called pinguecula. They are normal fatty deposits and do not require treatment. Occasionally, they will get inflamed and cause some local irritation. Usually over-the-counter lubricating drops are all that are necessary to alleviate symptoms.

At the same time, it is impossible to know without looking at you whether these bumps are pinguecula or something else that could be more serious. You should get an eye examination by an ophthalmologist.

bsattin: I've heard about an implantable lens instead of LASIK. Which is best?

Dr__Richard_Gans: Each has its advantages and disadvantages. Some people are not candidates for LASIK because of the shape or thickness of their cornea. In these cases, the implantable lens is an option. Surgery to implant a lens within the eye, however, has more inherent risks than laser on the surface of the eye.

Insider: I had a malignant melanoma on my back 15 years ago but I was advised to have my eyes periodically checked by a specialist. Are there any specific visible signs that I should be looking for to be proactive?

Dr__Richard_Gans: Absolutely. To help detect it early, you should have eye examinations regularly. Melanomas can sometimes hide deep within the eye, often with no symptoms at all. The Cole Eye Institute is fortunate to have Arun Singh, M.D., one of the world's authorities in the diagnosis and treatment of ocular melanoma. I'm sure he would be happy to see you.

Anxious: Any way to keep the pressure down in your eyes? Glaucoma runs in my family.

Dr__Richard_Gans: The only methods to control pressure inside the eye involve medications, laser treatments, or surgery. If you have a family history of glaucoma, your risk of developing glaucoma are much higher than the general population. You should have eye examinations by someone familiar with diagnosing and treating glaucoma at least once a year.

aprilw22: I have Graves’ disease, but my thyroid levels are normal. I have a lot of physical symptoms: tremor, weight loss, and severe anxiety. My eyes swell and are very painful, and my vision is getting very bad. You and Dr. Julian have checked me several months ago and also had thyroid labs checked. All symptoms seem to come and go.  I'll feel good for a week then sick for a week. I also have severe muscle pain. My question is: could the Graves’ go away on its own someday or will it just get worse?

Dr__Richard_Gans: To be honest, that is a question better directed to an endocrinologist. What I can tell you is that the eye problems that are related to thyroid conditions can wax and wane, no matter what your body's thyroid hormone levels are. By the way, the Cleveland Clinic is having a thyroid disease online chat this coming Monday. Log back in then!

aprilw22: Can Graves’ eye disease go away on its own or will it get worse?

Dr__Richard_Gans: Graves’ disease is sometimes said to "burn itself out" and go away. On an individual basis, it's impossible to predict for whom that will happen

johnnnita: This is someone who submitted a question in advance (yesterday) about ocular vein occlusion. Will this be answered?

Dr__Richard_Gans: This question was answered earlier in the chat. Please click on transcripts to review the response.

stella: I have used hemestapin for three to four years. Could that cause “red eye color?”

Dr__Richard_Gans: I'm not familiar with hemestapin.

family_fun: I never had a lazy eye growing up, but now that I am in my 30s I noticed that when I take my contacts out or glasses off, my right eye will turn inward. Should I be concerned about this? Is there something I can do to fix this?

Dr__Richard_Gans: An eye that drifts inward is not really a "lazy eye." Lazy eye - or amblyopia - refers to an eye that is structurally normal, but does not see well. Sometimes, small deviations in the position of an eye can get worse over one's lifetime. If they become significant, there is surgery that can be done to re-align the eye. At the Cole Eye Institute, we have three surgeons that routinely care for these types of problems.

forgetful: I was diagnosed with keratoconus two years ago and my glasses worked fine to correct my vision. About a month ago I started to notice that my glasses were not working as well. What other options are there?

Dr__Richard_Gans: Glasses with a new prescription may still be an option. If not, contact lenses can oftentimes provide good vision for keratoconus patients when glasses no longer work. If the problem progresses to such a point that vision is unacceptable, corneal transplantation can restore quality vision. Physician/scientists at the Cole Eye Institute of the Cleveland Clinic are investigating exciting new options that might restore vision to keratoconus patients without having to resort to corneal transplantation. These advancements may happen in the near future.


GENERAL QUESTIONS

hudsonrose: My husband had double detached retinas and was operated on at The Cole Center, and his sight was saved. My eye doctor offers a computerized test as a separate procedure, not included in her regular refractive eye exam, if I want it. Would this test have detected his problem before it reached the level requiring emergency surgery, and will it prevent me from the same issue? Why isn't this testing mandatory if it can detect this or other problems with the eyes?

Dr__Richard_Gans: It is not clear from your description what the extra computerized test is. It is probably a test to map out peripheral vision. Such a test would not necessarily find a retinal detachment before it requires surgery. The best examination for retinal detachment is a detailed examination through dilated pupils by a qualified ophthalmologist.

Anxious: Can you coordinate care with my doctor, since I can't get to the Cleveland area very often?

Dr__Richard_Gans: Certainly. We make every effort to coordinate care with physicians in all areas of the world to provide continuity to your health care.

moon_flower: Does Cole Eye have regional locations where I can see an ophthalmologist?

Dr__Richard_Gans: Yes. The Cole Eye Institute has ophthalmologists at the following regional locations: Beachwood, Hillcrest Hospital, Independence, South Pointe Hospital, Strongsville, and Twinsburg. Here is a link to location and appointment information, as well as physicians at those sites: http://my.clevelandclinic.org/eye/about/regional_opthalmology.aspx.

Anxious: Are there any vitamins or supplements to help vision?

Dr__Richard_Gans: The only truly scientific evidence says there are specific antioxidants and minerals that slow the progression in a large percentage of people who are at "high risk" for macular degeneration. Otherwise, all suggestions for vitamins are anecdotal. It is certainly true that vitamin deficiencies can have a negative effect on vision. So it is probably a good idea to take a regular multivitamin on a daily basis if you think you don't get full nutrition through your diet.

JoeB: Any recommendations in the Chicago area or should I travel to Cleveland? Also, is Alphagan P safe to use off label?

Dr__Richard_Gans: I'm not aware of anyone in the Chicago area, although there may be someone. Alphagan P is a good and safe medication for treating glaucoma, but it does have side effects and risks -- just like all medications. If you are followed regularly by an ophthalmologist familiar with its use, and if it is truly helping your symptoms, it is probably safe to continue using it.

hudsonrose: http://content.usatoday.com/communities/sciencefair/post/2011/01/embryonic-stem-cell-trial-to-test-macular-degeneration-treatment/1 Sorry. I read about this in USA Today and I thought a trial indicated the FDA was willing to try a proven procedure from Europe in the hopes of making it available here.

Dr__Richard_Gans: It looks as though these trials are just getting started. We'll hope for positive results.

JoeB: Are you aware of Morris Waxler's petition to the FDA to ban LASIK?

Dr__Richard_Gans: No, sorry/

JZImaging: Are you a retina specialist or can you recommend a retina specialist in the Lake County area or at the Clinic?

Dr__Richard_Gans: I am predominantly a cataract surgeon. Justis Ehlers, M.D., is a wonderful retina specialist who sees patients in the Hillcrest Medical Center in Mayfield Heights, very close to Lake County.

johnnnita: What type of specialist would you recommend with regard to my symptoms described in an earlier chat question (i.e. ocular vein occlusion of mother; specifically the symptoms I have with regard to double vision?

Dr__Richard_Gans: A neuro-ophthalmologist would be the person to address your double-vision issues. At the Cole Eye Institute, Drs. Kosmorsky and Lystad are neuro-ophthalmologists. With regard to vein occlusions, any of our many retina specialists would be happy to be of assistance.

JoeB: I know of a surgeon in Jacksonville FL, who claims to fix refractory problems and can easily fix cataracts after RK and LASIK. Should I be apprehensive of his claims?

Dr__Richard_Gans: We all do our very best to try to correct problems when patients are unhappy. I'm not familiar with this individual, by location. When in doubt, there is nothing wrong with getting a second opinion

JoeB: Does pupil size really decrease with age?

Dr__Richard_Gans: Yes. Usually pupils are larger in children and smaller in adults. This does not, however, imply any change in vision as a result.


Closing

Cleveland_Clinic_Host: I'm sorry to say that our time with Dr. Richard Gans is now over. Thank you again Dr. Gans for taking the time to answer our questions today about Keeping an Eye on Your Vision – Comprehensive Ophthalmology.

Dr__Richard_Gans: Thank you all. It's been great! If we can be of any assistance, please feel free to contact the Cole Eye Institute at the Cleveland Clinic.


More Information
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