Diet and Eye Health

Patients often ask me if it’s really true that carrots are beneficial for eye health. It is indeed true that carrots are a good source of beta carotene, a precursor to Vitamin A, and Vitamin A deficiency is one of the leading causes of blindness in the developing world. However, carrots alone are not sufficient to preserve and maintain eye health.   A well-balanced diet may also not be enough for patients with certain eye conditions, even though certain vitamins and nutrients have been found to be helpful in preventing and/or treating common ailments such as macular degeneration and dry eye syndrome.  Macular degeneration (MD) is a condition that affects the elderly, robbing patients of their central vision and significantly impacting quality of life. Those with macular degeneration often cannot drive, read, or recognize the faces of their loved ones. There are two types of macular degeneration- wet and dry. Recent advances in treatment have made the wet type somewhat easier to manage with injections of medication inside the eye on a regular basis. Unfortunately, for patients with the dry type, there are really no effective treatments available.

The National Eye Institute, a division of the National Institute of Health (NIH) performed a study that indicated that a specific formulation of a combination of vitamins and minerals prevented the progression of macular degeneration. The Age-Related Eye Disease Study 2 (AREDS2) formula includes Vitamins C, E, Zinc, Copper, omega-3 fatty acids, and the carotenoids Lutein and Zeaxanthin. The carotenoids are found naturally in green leafy vegetables and are natural antioxidants found in the retina that may help absorb damaging ultraviolet light. Based on the results of this study, the NEI recommends that patients who have been diagnosed with intermediate macular degeneration in either eye or those with advanced wet or dry MD in one eye take the AREDS2 formula as it may delay progression of the condition. These supplements are generally safe, but I always advise patients to consult with their primary care physician, as many older patients take other supplements, and prescription or over the counter medications that can interfere with each other.

Many younger patients ask me what they should do if they have a family history of macular degeneration. While genetics play a role in MD, it is not yet well understood, so it is difficult to assess the risk of development of the disease in these patients. It is clear from the NEI study that the AREDS2 formula was only found effective in patients who unfortunately already have MD. For those with a family history, I recommend the following common-sense advice to reduce the risk: a diet rich in green leafy vegetables, refrain from smoking, quality sunglasses while outdoors, a regular daily multi-vitamin, and a yearly dilated eye exam.  Much more common but less debilitating is dry eye syndrome (DES). This condition is characterized by red, burning, irritated eyes, blurry fluctuating vision that may clear with a blink, tearing, and an overall sense of eye fatigue or difficulty tolerating contact lenses. A great number of my patients have DES, ranging from mild and annoying to severe and constantly bothersome. There are many treatments for DES, including over the counter or prescription drops, environmental modification, eyelid hygiene, and LipiFlow treatments to heat and express the gland in the eyelid to produce more oil. In my dry eye center, we perform an extensive workup to determine whether the patient has dry eye and if so, what type they have. I then tailor my treatment regimen based on the specific patient. In all cases omega-3 fatty acids are a part of the treatment. Multiple studies have shown decreased inflammation of the ocular surface and improved tear production in patients taking omega-3 fatty acids.

Not all omega-3 preparations are the same, however. I generally recommend a fish oil based product that is high in the polyunsaturated fats EPA and DHA. Many commercially available fish oil products are difficult to absorb, leave a fishy aftertaste due to alcohols, and are drastically lower in the crucial EPA and DHA. After experimenting with various forms I have been recommending PRN (Physician Recommended Nutriceuticals) products. These omega-3s are of the highest quality, providing the most concentrated amounts of essential fatty acids without the alcohol and unpleasant effects. So while a dinner of salmon with a side of carrots may be a good dietary choice, for many people with serious eye conditions, specific over the counter nutritional supplements are vital to preserve and maintain eye health.

Back to School…

…But an eye exam first!

As the days start getting shorter and the kids come home from camp, thoughts turn from the playground to the classroom. In addition to shopping for school supplies, and bugging their kids to complete their summer reading, parents should make sure that their child’s visual needs are attended to with an annual eye examination.   Some parents are under the mistaken assumption that if their child is having trouble seeing they will tell their parent or teacher. In my experience, this is not always true. Some children might be afraid of the eye exam, or don’t want to wear glasses. Others might be worried that their teacher would think that they are not paying attention if they ask the teacher to read something off the board. Regardless, an exam by an ophthalmologist can easily determine the need for glasses.

 

This simple and non-invasive exam can often detect a refractive error that, when corrected with glasses or contact lenses, can make the difference between a successful student and one who might struggle.  Simply stated, a refractive error is a change in the shape of the eye that causes images to be out of focus on the retina, the film in the back of the eye. By simply refocusing the image with glasses or contact lenses the once blurry image becomes clear again.  The most common refractive error is myopia, or nearsightedness. These children can see much better close up than far away. At home, parents may notice that their kids sit too close to the TV or read with the book up to their faces. Less common is hyperopia, or farsightedness. In contrast, farsighted children have a harder time reading and may get headaches after long periods of close work.  Astigmatism happens when the cornea, the clear front surface of the eye, is shaped more oblong, like a football, rather than being perfectly round. Astigmatism can be found in combination with nearsightedness or farsightedness, or by itself.   For younger children, it is critical that the refractive error is diagnosed early, because a large degree of myopia, hyperopia or astigmatism in both eyes, or a large difference between the two eyes, can lead to a preferential relationship between the stronger eye and the brain to the detriment of the weaker eye. This can lead to a weak or lazy eye that can be difficult or impossible to fully correct once the child reaches early adolescence.  Fortunately, all refractive errors can be corrected with glasses, and most with contact lenses.

 

Once the eye exam has been done, and a prescription for glasses given, choosing glasses that your child will actually want to wear to school is next. Many parents choose to buy more than one pair to ensure against the inevitable loss or breakage. Polycarbonate, shatter-resistant plastic lenses are the law for children. I also recommend scratch resistant lenses, and anti reflective coating, which can help with the glare of fluorescent lighting off of smart boards in many classrooms. The antireflective coating can also lessen the reflection of your child’s glasses if they are photographed with them on.  Many parents ask me when is an appropriate age to fit their child with contact lenses. In my practice, I don’t have a set age. Contact lenses are a responsibility, and good hygiene is critical. If your child is the one who leaves the toothpaste uncapped and the water running and has to be reminded to use deodorant, then they are probably not ready for contacts. I once fit a precocious eight-year-old with lenses, and I have plenty of eighteen-year-olds who still shouldn’t be wearing them.  Contacts come in all varieties. While hard or gas-permeable lenses still exist, a vast majority of my patients wear soft disposable lenses. Gone are the days of a single lens that patients keep for an entire year. The disposal schedule varies from 3 months to monthly, to 2 weeks or even daily disposables. The choice of lens depends upon the patient and their needs. The daily disposable lenses are the ultimate in convenience, since they eliminate the need for solutions or storage cases. It is less to pack on a business trip or vacation. I often recommend these lenses for kids going to sleep away camp where hygiene will be suboptimal at best.

 

Another option for kids college age and older, when they tire of glasses and contact lenses, is to do what I did- have laser vision correction performed on your eyes. Speaking as both a patient and a surgeon, I echo my many happy patients and can honestly say that it was one of the best decisions of my life. After almost 30 years of daily glasses and contact lenses wear, I’m still amazed when I wake up in the morning and I can see clearly, even 12 years after my surgery. Unlike glasses and contact lenses, not every refractive error can be corrected, and not everyone is a candidate for the procedure, but a simple consultation can usually determine if laser vision correction is appropriate. But that is a topic for my next column….

Not Your Parent’s Cataract Surgery

In my 20 years as an ophthalmologist, nothing has given me more gratification than the ability to remove a cataract and restore someone’s vision.  A cataract is a clouding of the natural lens that occurs with advancing age.  Trauma, certain medications, and diseases can also cause cataracts, but like wrinkles, anyone who lives long enough will eventually develop cataracts.  Cataracts are so common that surgery to remove them is the most common surgical procedure performed in the United States. Symptoms of cataracts include blurry vision at distance and/or near, difficulty seeing or driving at night, and glare from sunlight or oncoming headlights.

The good news is that cataract surgery has evolved from a very complicated and risky procedure with a prolonged and difficult recovery period to a marvel of modern medicine.  Modern cataract surgery is performed in an outpatient setting, with most patients returning to normal activity within a few days.

In the early days, cataracts were removed by “couching”, which involved striking the eye with a blunt object to dislocate the clouded lens into another area inside the eyeball.  Through the 1960s and 1970s, the lens was removed in one large piece through an incision in the eye, which meant stitches, long recovery periods, and often, hospitalization.  After surgery, since patients could not see without a lens inside their eye, they required thick “coke bottle” type glasses.

Artificial lens implants at the time of surgery became commonplace in the 1980s. They were invented when Sir Harold Ridley, a pioneering British ophthalmologist, discovered that World War II fighter pilots who sustained eye injuries and had pieces of their plastic windshield inside their eyes tolerated the material without infection or inflammation.

These days, cataracts are removed by breaking up the clouded lens with tiny ultrasound equipment and vacuuming out the debris through a tiny 3mm opening.  These incisions are so small they rarely require stitches and seal themselves.  Instead of “coke bottle” glasses, a foldable lens implant made of acrylic or silicone is inserted through the same tiny 3mm incision and positioned inside the space left by the cataract.  This modern procedure results in very rapid recovery and little to no down time from regular daily activities.

In the past few years, the explosion in technology has taken a very safe and successful surgery and made it even better.  New vision correcting lens implants have allowed me to correct my patients vision and eliminate the need for distance and reading glasses after surgery.  It is very exciting to hear patients describe their experiences with independence from their old glasses after surgery, especially when they were so dependent on glasses beforehand.  With the use of astigmatism-correcting and multifocal lens implants, I can correct the vision of almost any cataract patient at the time of surgery.  Post-operative day one, when I remove the eye patch in my office, is often the most satisfying day for everyone.

The advances don’t stop with lens implants.  Our surgery center was among the first in New Jersey to offer laser-assisted cataract surgery.  This new technology automates certain delicate parts of the procedure, softens the cataract making it easier to remove with ultrasound, and makes the incisions with increasing precision.  We also have a device that attaches to the operating room microscope called an aberrometer that measures the eye during surgery, improving the selection of the lens power and improving my patients resulting vision.

All in all, it’s an exciting time to be a cataract surgeon.  I set the bar very high for my patients and myself.  I not only aim to remove the cataract safely and successfully, but to eliminate the need for glasses to the best of my ability.

Despite all the new technology, I still use my skills in the old fashioned technique, when I travel to third world countries.  There we don’t have access to modern ultrasounds and microscopes, so I still remove cataracts in one piece.  Even with the old-fashioned surgery, I get immense gratification in restoring sight.

 

A Message from Dr. Farbowitz

I just returned from the annual meeting of the American Society of Cataract and Refractive Surgery (ASCRS) in New Orleans. It was a whirlwind 3 days of lectures, presentations and demonstrations of the latest and greatest techniques and technologies in ophthalmology. It reminds me of why I became an ophthalmic surgeon more than 20 years ago.

In what I expect to become a regular blog, I hope to be able to open a window to the wonders of the human eye and the amazing things that we can do in this incredible specialty.

So first, a little about me. I’m a comprehensive ophthalmologist, which means I take care of a wide variety of eye conditions in patients of all ages. I have a special interest in laser vision correction and new technology cataract surgery and lens implants. I have been in practice in Short Hills, NJ for the last 15 years.

I was one of those kids who knew he wanted to be a doctor, specifically an ophthalmologist from a young age. Embarrassingly, my ambition in my high school yearbook was “opthalmologist” misspelled. (Many people miss one of the “h”s. It’s ophthalmologist. It makes it worse that I was the editor of the yearbook! But fortunately my grades were better than my spelling and proofreading. I went to Johns Hopkins in Baltimore, as premed. Even back then, I enjoyed writing, and chose a writing seminars minor. I was science editor of the school paper, and wrote for the alumni magazine. Medical school at NYU followed, and then training at Long Island Jewish medical center and UCLA. So that’s my path to my current practice.

In the day to day practice of medicine, it is easy to lose sight (no pun intended) of the advances that have taken place even since I began practice in the mid ’90s. Like only a few other surgical specialties, ophthalmology has been the beneficiary of the explosive growth in technology.

Every year when I return from one of these conferences, my head spins with the myriad of ways that I can improve the quality of my patient care. Whether it is an automated camera that takes panoramic pictures of the patient’s retina through a tiny pupil eliminating the need for dilation, or a sophisticated microscope attachment that measures the eye during cataract surgery and predicts lens implant power, the possibilities seem endless.

So while I’m at the midpoint of my career as a surgeon, I feel like a kid in a candy store. And things will only continue to get better. We are blessed in our field that we have some of the brightest and most creative minds in medicine and biotechnology at work making major advances in eye care and surgery.

Keep your eyes peeled (I have to quit with these puns!) on this space for regular posts on the wonders of the human eye and some exciting developments that I think will really help my patients.

A word about New Orleans- this was my second trip back since hurricane Katrina 11 years ago. The city pulses with vibrancy and color, and southern hospitality is alive and well in the big easy. But As I passed the superdome and spent time in the convention center, I couldn’t help but think about the loss of life and property that happened here a short decade ago. New Orleans is back, but the scars remain.