Age-related macular degeneration - 2012 Lancet review

From the The Lancet:

Age-related macular degeneration is a major cause of blindness worldwide. With ageing populations in many countries, more than 20% might have the disorder.

Advanced age-related macular degeneration is associated with progressive visual impairment. It includes two subtypes:

- neovascular age-related macular degeneration (wet)
- geographic atrophy (late dry) macular degeneration

What are the risk factors for macular degeneration?

Major risk factors include:

- cigarette smoking
- nutritional factors
- cardiovascular diseases
- genetic markers, including genes regulating complement, lipid, angiogenic, and extracellular matrix pathways

How to diagnose macular degeneration?

Accurate diagnosis combines clinical examination and investigations including:

- retinal photography
- angiography
- optical coherence tomography

What is the treatment for macular degeneration?

Dietary anti-oxidant supplementation slows progression of the disease.

Treatment for neovascular age-related (wet) macular degeneration includes intraocular injections of anti-VEGF agents. The two commonly used anti-VEGF therapies, ranibizumab and bevacizumab, have similar efficacy.

Future treatments include inhibition of other angiogenic factors, and regenerative and topical therapies.

References:

Age-related macular degeneration. The Lancet, Volume 379, Issue 9827, Pages 1728 - 1738, 5 May 2012.
Image source: Wikimedia Commons.

Myopia - 2012 Lancet review

From the Lancet:

Myopia (nearsightedness) has emerged as a major health issue in east Asia, because of:

- increasingly high prevalence in the past few decades. It now affacts 80-90% in school-leavers.
- sight-threatening pathologies associated with high myopia, which now affect 10-20% of those completing secondary schooling in east Asia.

Similar, but less marked, changes are occurring in other parts of the world.

The higher prevalence of myopia in east Asian cities seems to be associated with increasing educational pressures, combined with life-style changes, which have reduced the time children spend outside.

There are no reported major genes for school myopia, although there are several genes associated with high myopia. Any genetic contribution to ethnic differences may be small.

There are some optical and pharmacological interventions that seem promising for preventing the development of myopia or slowing its progression, but the evidence is still preliminary.

References:

Myopia. Prof Ian G Morgan PhD a b , Prof Kyoko Ohno-Matsui MD c, Prof Seang-Mei Saw PhD. The Lancet, Volume 379, Issue 9827, Pages 1739 - 1748, 5 May 2012.
Nearsighted kids may get worse in winter http://trib.in/VcvmC1 -- Myopia progression seem to decrease in periods with longer days and to increase in periods with shorter days. Children should be encouraged to spend more time outside during daytime to prevent myopia (study) http://buff.ly/X1cFSm
Image source: OpenClipArt.org

New treatment for dry eyes: "LipiFlow" uses heat and pressure to open blocked eyelid oil glands

The Meibomian glands (or tarsal glands) are sebaceous glands at the rim of the eyelids, responsible for the supply of meibum, an oily substance that prevents evaporation of the eye's tear film. They prevent tear spillage onto the cheek, trapping tears between the oiled edge and eyeball, and make the closed lids airtight. There are approximately 50 glands on the upper eyelids and 25 glands on the lower eyelids. The glands are named after Heinrich Meibom (1638–1700), a German physician (source: Wikipedia).

The LipiFlow Thermal Pulsation System uses heat and pressure to open blockages of the eyelid (Meibomian) glands. The treatment was approved by the FDA in 2011. Here is more information: http://lipiflow.com

Here is a Mayo Clinic video about the procedure:

Myopia, the most common refractive error, has a prevalence of 10-30% in Western countries, but as high as 80% in Asia

Myopia (nearsightedness), the most common form of refractive error, has a prevalence of about 10-30% in most Western countries, but this figure is as high as 80% in parts of Asia. Furthermore, myopic refractive error is likely to progress during school years, and maintaining appropriate spectacle correction requires regular services for children in these age groups.

A study of self correction of refractive error among young people in rural China showed that although visual acuity was slightly worse with self refraction than automated or subjective refraction, acuity was excellent in nearly all these young people with inadequately corrected refractive error at baseline. Inaccurate power was less common with self refraction than automated refraction.

Self refraction could decrease the requirement for scarce trained personnel, expensive devices, and cycloplegia in children’s vision programs in rural China.

References:

Self correction of refractive error among young people in rural China: results of cross sectional investigation. BMJ 2011; 343 doi: 10.1136/bmj.d4767 (Published 9 August 2011).

Nearsightedness (myopia) becoming more frequent, affects 42% of Americans

Correcting refractive error in low income countries. BMJ 2011; 343 doi: 10.1136/bmj.d4793 (Published 9 August 2011).

20-20-20 rule: For every 20 minutes of reading a screen take a 20-second eye break, look at something beyond 20 feet. NYTimes, 2012.

Nearsighted kids may get worse in winter http://trib.in/VcvmC1 -- Myopia progression seem to decrease in periods with longer days and to increase in periods with shorter days. Children should be encouraged to spend more time outside during daytime to prevent myopia (study) http://buff.ly/X1cFSm

Image source: OpenClipArt.org.

Glaucoma: Aruna's story (video)

From NHS Choices YouTube channel: Glaucoma is a group of eye conditions that affect vision. Aruna talks about her diagnosis and subsequent treatment.

A consultant ophthalmologist explains what glaucoma is, how it can affect your vision and how it can be treated:

Accessibility Extensions for Chrome Browser - Text-to-Speech and More

ChromeVox is just one of the Google Accessibility extensions. Be sure to check out ChromeVis, ChromeShades, and ChromeLite as well. The text-to-speech (TTS) programs convert text or web documents to human speech. Does it sound like a human voice? Not really, it is a computer-generated voice but it is as close to human as it gets. You can adjust the speed, repeat, or change the pitch of the voice.

ChromeVox

The ChromeVox screen reader is an extension to Chrome that brings the speed, versatility, and security of Chrome to visually impaired users.


Using Google Document List with ChromeVox that provides accessibility features for vision impaired users of Google Docs.

Other text-to-speech extensions include:

Chrome Speak - select to speak with offline TTS engine.

SpeakIt! Select text you want to read and listen to it. SpeakIt converts text into speech so you no longer need to read.


SpeakIt reads selected text using Google TTS (Text-to-Speech) with language auto-detection.

Text-to-Speech in Pocket app (formerly “Read Later”) http://goo.gl/ikFNN

Balabolka

If you are not a Chrome user, Balabolka is a free and portable Text-To-Speech (TTS) program that is browser-independent. No installation is required.

You don't have to be visually impaired to benefit from TTS programs. For example, I use Balabolka several times a week to convert long articles from medical journals or newspapers to standard MP3 files. The files are then uploaded to Google Docs and I download them when I have some time to listen to the articles.

ChromeVis

Magnify and change the color of any selected text. Use the mouse or the keyboard to move the selection around the page.


How ChromeVis works.

ChromeShades

ChromeShades is an easy tool to help you make your site more accessible to blind users.

References:

Hear Web Text with Google Chrome Speak
New Text-to-Speech API for Chrome extensions

Regulations allowing optometrists to use lasers pass; opponents may sue for violation of Open Meetings Act

Though ophthalmologists and the Kentucky Medical Association strongly objected, a legislative committee passed regulations Tuesday that will allow optometrists to perform some eye surgeries using lasers. In answer, opponents says "they might file legal action against the Kentucky Board of Optometric Examiners, which drafted the regulations, for failing to comply with the state's Open Meetings Act," reports Beth Musgrave of the Lexington Herald-Leader.

The regulations, authorized by Senate Bill 110 in this year's General Assembly, now go to another legislative panel for final approval. The bill has been cause for controversy, in large part because it passed through the legislature in a swift 12 days. Oklahoma is the only other state that gives similar operating privileges to optometrists.

Ophtalmologists said Tuesday the optometric board "used a task force appointed by the state optometric association, a trade group, to develop the regulations, and those meetings were held in secret with no public input," Musgrave reports. Legislators and optometrists disagreed, saying public comment was allowed at an open meeting in July, and the regulations were altered after task force members took the comments into consideration.

Dr. Woodford Van Meter, president of the Kentucky Academy of Eye Physicians and Surgeons, said patient safety is at risk of optometrists are allowed to perform the procedures, in part because the bill states they only have to receive 32 hours of training and show they can do the procedure once before they can use lasers. By contrast, Van Meter said ophthalmologists have 17,000 hours of surgical training and perform surgeries hundreds of times before being allowed to do them on their own.

If the regulations pass, optometrists may be allowed to perform the surgeries by year's end. (Read more)

Optometrists, ophthalmologists renew battle over optometrists' ability to perform medical procedures

Ophthalmologists renewed their fight yesterday against new rules "that would allow optometrists to perform more complex procedures that critics say will endanger patients," Mike Wynn of The Courier-Journal reports. The Kentucky Board of Optometric Examiners held the hearing on regulations that would implement a law passed quickly by the General Assembly after a years-long lobbying effort by optometrists and their trade group's executive director, Darlene Eakin, left. (C-J photo by Pam Spaulding)

The law allows optometrists to do limited laser treatments, "injections of medicine and removal of benign lesions from eyelids," Wynn writes. The only other state that allows them to do so is Oklahoma, but critics say no problems have been reported in that state and have noted that only 41 Kentucky counties have ophthalmologists.

Ophthalmologists "charged that the rules are not stringent enough to ensure optometrists — who are not medically licensed — can perform the treatments without causing harm," Wynn writes. The rules would require optometrists who want to expand their practice to take classes on more than 20 medical topics, pass tests, get clinical experience and "demonstrate competency to a board-approved expert," Wynn notes. "Lexington ophthalmologist Ken Weaver said wording in the draft resembles 'vague ideas,' rather than medical standards, and could allow an optometrist to perform eye surgeries after a 16-hour course from an unqualified instructor." (Read more)

New Kentucky optometry law prompting legislators in other states to consider same or similar changes

Now that Kentucky lawmakers have allowed optometrists to expand their scope of care, legislators in Nebraska, South Carolina and Texas may follow suit. They are looking at legislation that would allow optometrists to perform minor surgeries that were previously only allowed to be done by ophthalmologists, who are medical doctors.

Despite objections from several physician organizations — who say optometrists lack the medical training to perform the surgeries or deal with the complications — The Better Access to Quality Eye Care law was signed by Gov. Steve Beshear this winter. It lets optometrists perform a range of new procedures, including post-cataract surgery and two types of glaucoma surgery, reports Carolyne Krupa of American Medical News. The bill caused controversy partly because of the amount of campaign contributions, totaling almost $400,000, that optometrists made to all but one legislator and Beshear in the past two years.

Bills being considered in Nebraska and Texas would allow optometrists to "remove skin lesions from eyelids" and perform the same eye surgeries now permitted in Kentucky. The bills in Nebraska, Texas and South Carolina would also let optometrists make injections in the eyelid.

In 1998, Oklahoma because the first state to allow optometrists to perform some eye surgeries. Earlier this year, Kentucky became the second state nationwide. (Read more)

1 in 40 adults older than 40 years has glaucoma

One in 40 adults older than 40 years has glaucoma with loss of visual function.

Adults have one of the two forms of glaucoma:

- open-angle glaucoma

- angle-closure glaucoma

Diagnosis

At least half of glaucoma cases are undiagnosed. Glaucoma is mostly asymptomatic until late in the disease when visual problems arise. Vision loss from glaucoma cannot be recovered.

Treatment

Glaucoma is treated with daily eye-drop drugs, but adherence to treatment is often unsatisfactory.

Similarities to the pathogenesis of common CNS diseases mean that common neuroprotective strategies might exist. Successful gene therapy has been used for some eye diseases and may be possible for the treatment of glaucoma in the future.

References:
Glaucoma. The Lancet, Volume 377, Issue 9774, Pages 1367 - 1377, 16 April 2011.

Image source: Eyelashes, Wikipedia, Steve Jurvetson, Creative Commons Attribution 2.0 Generic license.

Adaptive eyewear - BMJ video

BMJ medical innovations: Prof. Josh Silver from the Centre for Vision in the Developing World introduces adjustable eyewear that can be made for £1 and fitted by patients themselves.

What to look for when buying sunglasses?

From the NYTimes:

Unprotected exposure to sunlight can cause significant damage to the eyes

Sunlight can burn the surface of the eye, causing a temporary and painful condition known as photokeratitis. Over time, unprotected exposure can contribute to cataracts, as well as cancer of the eyelids and the skin around the eyes.

UV exposure also may increase the risk of macular degeneration, the leading cause of blindness in people over age 65.

What to look for when buying sunglasses?

Look for labels indicating at least “98 percent UV protection” or that it “blocks 98 percent of UVA and UVB rays.” If there is no label, or it says something vague like “UV absorbing” or “blocks most UV light,” don’t buy them.

For the best defense, look for sunglasses that “block all UV radiation up to 400 nanometers,” which is equivalent to blocking 100 percent of UV rays

Sunglasses should cover the sides of your eyes to prevent stray light from entering. Wraparound lenses are best. Look for close-fitting glasses with wide lenses. Avoid models with small lenses, such as "John Lennon-style" sunglasses.

UV protection is not related to how dark the lens is. Sunglasses tinted green, amber, red and gray may offer the same protection as dark lenses.

Polarized lenses block the horizontal light waves that create glare. But remember, polarization in itself will not block UV light.

You should be able to find a pair of drugstore sunglasses for $10 to $20 that provide all the protection you need.

References:
Let the Sunshine in, but Not the Harmful Rays. NYTimes, 2011.

Image source: OpenClipArt.org, public domain.

Beshear signs first bill of session; optometrists will benefit

Gov. Steve Beshear has signed legislation that will significantly increase the scope of care optometrists can provide, making it the first bill to become law in this session of the General Assembly.

"Access to quality health care is a critical issue for families across the commonwealth," he said in a press release. "After careful consideration, along with meetings with many interested parties, today I signed Senate Bill 110 to give Kentuckians greater access to necessary eye care."

The bill made an unusually speedy passage through the General Assembly after being filed Feb. 7. The Courier-Journal reported earlier this month optometrists have given a total of $400,000 in campaign contributions to legislators, the only exception being one who is a physician. Beshear's re-election campaign has also received optometrists' money.

The law will allow optometrists, who do not attend medical school, to perform more types of procedures, most notably one that uses a laser to fix complications that can arise from cataract surgery. Only optometrists in Oklahoma are likewise allowed to use lasers while treating their patients; in every other state, only opthalmologists can. The law also allows optometrists to prescribe certain drugs and lets the state Board of Optometric Examiners define what procedures optometrists can legally perform.

"In order to ensure the highest degree of oversight, I will be meeting with the Board of Optometric Examiners to make sure that providers of these services undergo extensive training," Beshear said. "I believe this new law will mean more Kentuckians can get the eye care they need." Optometrists practice in 106 counties in Kentucky. Two-thirds of the state's counties do not have an ophtalmologist, and supporters of the bill sais it will make eye care more accessible and affordable in rural areas.

Optometrists, ophthalmologists debate bill on TV after its passage

The bill to let optometrists perform some procedures now done legally only by ophthalmologists has passed both houses and is on the governor's desk, but members of both professions are debating its effects on television.

Leaders of the Kentucky Optometric Association and the Kentucky Academy of Eye Physicians appeared on cn|2's "Pure Politics" with Ryan Alessi on Insight cable Friday night, and are scheduled to appear on KET's "Kentucky Tonight" with Bill Goodman Monday at 8 p.m. EST.

Ben Gaddie of Louisville, president-elect of the optometrists' group, told Alessi that while the bill was passed only 11 days after it was filed, becoming the year's first to go to Gov. Steve Beshear, “We weren’t intentionally hiding anything … There are no secrets in Frankfort.”

Woodford VanMeter of Lexington, president of the ophthalmologists' group, "took issue with the ophthalmologists receiving limited time to raise their objections during committee hearings on the bill," cn|2 reports. (Click arrow to start video)

Optometrists' well-financed bill is first to clear General Assembly

The bill that would significantly increase the care optometrists can provide passed the House Friday morning by a 81-14 vote. The bill, which now heads to Gov. Steve Beshear's desk, is the first this session to clear both houses of the General Assembly, The Courier-Journal's Tom Loftus reports.

Since it was filed Feb. 7, Senate Bill 110 has been cause for controversy, in part because of its speedy passage. It passed the full Senate last week, passed the House Licensing and Occupations Committee Wednesday and was voted on by the full House this morning. Loftus notes that optometrists have made more than $400,000 in campaign contributions to legislators and Gov. Steve Beshear in the past two years.

The bill allows optometrists, who do not attend medical school, to perform more types of procedures, most notably one that uses a laser to fix complications that can arise from cataract surgery. Only optometrists in Oklahoma are likewise allowed to use lasers while treating their patients; in every other state, only ophthalmologists -- medical doctors trained to perform eye surgeries --  can. The bill also allows optometrists to prescribe certain drugs and lets the state Board of Optometric Examiners define what procedures optometrists can legally perform.

On Thursday, ophthalmologists voiced their displeasure, saying they believe rules were broken in passing the bill. The bill should have been heard by the Health and Welfare committees, not the licensing committees, they say. "We hope that someone in the House (which now has the bill) will appeal for this to be corrected and ... sent to the proper committee so that the facts can be heard," said Woodford Van Meter, president of the Kentucky Academy of Eye Physicians and Surgeons.

House Speaker Greg Stumbo and Senate Majority Floor Leader Robert Stivers, the bill's sponsor, disagreed, saying the bill affects the licensing of optometrists. Ophthalmologists note the Senate and House rules say the health committees have "general jurisdiction" over "matters pertaining to ... optometrists." (Read more)

How to protect your child's eyes from video games?

Dr. Paul Rychwalski of the Cole Eye Institute at the Cleveland Clinic talks to the local TV station WKYC about how you can protect your child's eyes from video games.

Twitter comments:

@pathophizz: shut them off? read them a book instead? go for a hike? geesh.

Senate quickly passes bill to allow optometrists to perform minor surgical procedures; ophthalmologists say that would be risky

"The Senate approved a bill Friday to allow optometrists to perform some surgical procedures on the eye and eyelid, brushing aside warnings from medical doctors who said optometrists are not qualified and could harm surgical patients," John Cheves reports for the Lexington Herald-Leader. Supporters of the bill said it would improve eye services in rural areas.

Prospects for Senate Bill 110 in the House are uncertain, but it passed the Senate 33-3 and optometrists have long been major financiers of legislators' campaigns. They have given almost $740,000 to state candidates since the Registry of Election Finance began keeping computerized records in 1997, and have won several legislative battles against ophthalmologists, medical doctors who specialize in eye matters.

The bill was filed Monday night and approved by the Senate Licensing and Occupations Committee the next day. "After ophthalmologists started calling, the Senate granted them a brief hearing Friday morning to air their complaints, although it did not stop the Senate vote," Cheves reports. Sen. Julie Denton, R-Louisville, chair of the Health and Welfare Committee, called the process a "kangaroo court" and said, "Just because we have a squeaky wheel doesn't mean we have to oil it immediately."

If the bill becomes law, optometrists could "remove lumps and bumps and use lasers to treat a few specified conditions, although they could not perform Lasik corrective surgery or any other procedure requiring general anesthesia," Cheves reports. "Optometrists told the committee that about two-thirds of Kentucky's counties don't have an ophthalmologist, especially in rural areas. . . . Oklahoma passed a similar law in 1998 with no serious problems, they added."

Oklahoma's law is the only one like it in the U.S., according to a commenter on the story, identified as "uk1234." Noting the bill language that would give the state Board of Optometric Examiners "sole authority to determine what constitutes the practice of optometry," the commenter wrote, "The fox will be in charge of the hen house." But a commenter named "taxus" replied, "If the training is adequate (long enough to be proficient) and the practitioner trainee is certified by a panel of peers in the licensing body, then it could prove to be a good idea for folks the 2/3 of the counties where these particular procedures are not now available." (Read more)

Diabetic retinopathy is identified in a third of people with diabetes

Diabetic retinopathy is a common microvascular complication of diabetes, and remains the leading cause of preventable blindness in working-aged people. It is identified in a third of people with diabetes and associated with increased risk of life-threatening systemic vascular complications, including stroke, coronary heart disease, and heart failure.

Optimum control of blood glucose, blood pressure, and possibly blood lipids remains the foundation for reduction of risk of retinopathy development and progression.

Timely laser therapy is effective for preservation of sight in proliferative retinopathy and macular oedema, but its ability to reverse visual loss is poor.

Vitrectomy surgery might occasionally be needed for advanced retinopathy.

New therapies, such as intraocular injection of steroids and antivascular endothelial growth-factor agents, are less destructive to the retina than are older therapies, and could be useful in patients who respond poorly to conventional therapy.

Future treatment modalities include inhibition of other angiogenic factors, regenerative therapy, and topical therapy.

References:
Diabetic retinopathy [Seminar]. Ning Cheung, Paul Mitchell, Tien Yin Wong. Lancet, 2010.

Intensifying glucose control and adding fenofibrate to simvastatin each reduced progression of retinopathy in DM2 http://goo.gl/htHIK

Ophthalmology Self-Guided Study Activity - ACP 2011 .

Contact lenses change color when blood glucose increases in diabetics

In the future, diabetics may be able to wear contact lenses that continuously alert them to variations in their glucose levels by changing colors - potentially replacing the need to routinely draw blood throughout the day.

The non-invasive technology, developed by Chemical and Biochemical Engineering professor Jin Zhang at The University of Western Ontario, uses extremely small nanoparticles embedded into the hydrogel lenses. These engineered nanoparticles react with glucose molecules found in tears, causing a chemical reaction that changes their color.

References:
Nanocomposites could change diabetes treatment. The University of Western Ontario, 2010.

Image source: OpenClipArt.org.

Glaucoma eye drops drug Latisse used OTC to make long eyelashes but some now face side effects

From the NYTimes:

Latisse is the same formula as Lumigan, Allergan’s eyedrops for glaucoma, which reduces eye pressure but also happens to grow lashes. Both are also known as bimatoprost ophthalmic solution. In early 2009, Allergan introduced the drug as a lash enhancer.

A former primary care doctor runs www.latisse.bz, which boasts that it is the “largest Latisse retailer.” All it takes to get Latisse mailed out — without ever seeing him — is filling out a medical history, which he reviews, and typing in a valid credit card number.

But if people use Latisse without seeing a doctor, the side effects may come as a big surprise.

Eyelid discoloration “may be reversible” according to the manufacturer. A rare side effect that has captured the most attention is the chance that one’s hazel or blue eyes could turn brown — forever.

References:
Long Lashes Without Prescription, but With Risks. NYTimes, 2010.

Image source: Eyelashes, Wikipedia, Steve Jurvetson, Creative Commons Attribution 2.0 Generic license.