Eye Doctors on Common Eye Conditions

Hadley Presents

Eye Doctors on Common Eye Conditions

Presented by Ricky Enger

Ricky Enger: Welcome to Hadley Presents. I’m your host, Ricky Enger, inviting you to sit back, relax, and enjoy a conversation with the experts. In this episode, we hear from specialists discussing diagnosis and treatment of several eye conditions, along with information about getting the most from your remaining vision.

You know, I’ve learned so much during my time as host of Hadley Presents, and I’ve gotten to chat with some really incredible guests. We have had topics on vision loss, ranging from art to technology to marriage, and pretty much everything in between I think. One thing that we heard a lot from many of our listeners was that they wanted to know more about vision loss itself. So they wanted to understand their own eye conditions better, and they wanted some idea of what to expect going forward. Thankfully we were able to find the guests who could speak to that really well. We’ve had a number of eye doctors and low vision specialists who were willing to share their time and their expertise with us, so we figured why not gather some of that info all in one place – kind of like a one-stop shopping for low vision information.

So I think one of the most common eye conditions is glaucoma. So many people have it, but it’s not actually caused by just one thing. There’s not even a single, definite symptom that tells you that you have it. So what exactly is glaucoma, and how does it get diagnosed. For the answer to that, we approached Dr. Jullia Rosdahl.

Dr. Jullia Rosdahl: So, glaucoma is actually a group of eye diseases, and what they have in common is that the optic nerve, which is the cable that connects the eye to the brain, it's when that optic nerve becomes thinned out because of those neurons, those retinal ganglion cells that, of those neurons dying. So when the nerve dies off like that, people lose vision and it usually affects their peripheral or side vision first, in glaucoma. The most common type of glaucoma in the United States is primary open-angle glaucoma, and one of the main problems that we have with glaucoma is that people have it and they don't know it, because the vision loss happens really slowly.

And once you lose vision from glaucoma we can't get that vision back. So early detection and diagnosing glaucoma early is really important for saving sight. You asked about risk factors, so they include having a family history of glaucoma, older age is an important risk factor for glaucoma too. And actually, Black race and Hispanic ethnicity are risk factors, although a lot of white people can get glaucoma too.

Ricky Enger: Okay, so how does someone get to the point where it’s clear that they should be screened for glaucoma. And what is a typical glaucoma exam like?

Dr. Jullia Rosdahl: The scenario that we hope for is that people are going along in their regular lives, and they're getting regular complete eye exams with their local eye doctors. That local eye doctor recognizes some early sign. Maybe the eye pressure is a little elevated, or maybe the optic nerve looks a little suspicious, family history is noted. And that savvy local eye doctor either does some of the glaucoma testing themselves or refers them to someone like me as a glaucoma specialist. And then I see them. We do what we call a glaucoma evaluation, which is a pretty lengthy visit in-clinic, where they get a lot of special testing and an in-depth eye exam. And we ferret out whether they do have glaucoma, or just some risk factors that need to be followed.

So that's the scenario that we hope for, where the disease is diagnosed early before really any vision loss has occurred, and we can start treatment early and prevent vision loss. So we also get referrals for help in managing patients who've already sustained vision loss from glaucoma or already have advanced glaucoma. And sometimes the reasons that they come to us are because they need surgery, or they need some additional treatment that that local eye doctor is not able to provide. So there are lots of different ways that patients come to see a glaucoma specialist, but we always hope that they're coming early enough where we can save vision, and that frequently is the case. Actually, most people who are diagnosed with glaucoma and treated for glaucoma don't go blind from it.

Ricky Enger: Okay, that’s awesome news. So then what can someone expect as far as how glaucoma is treated?

Dr. Jullia Rosdahl: The main treatment for glaucoma is to lower eye pressure. And we have a lot of different ways to do it. Typically, we'll start with eye drop medications or a laser treatment to the drain of the eye. And then, there are also surgical treatments that we typically reserve for cases where we cannot control the glaucoma with the drops or laser or where those treatments are just not effective or not possible. For example, a patient who has a lot of eye drop allergies, cannot tolerate any of the drops, then surgery may be considered for a more mild case as well.

Ricky Enger: I imagine eye drops aren’t at the top of anyone’s list of favorite things. Still, it’s helpful to know how much they can really do, and what to expect if this is the treatment you’ll be working with.

Dr. Jullia Rosdahl: It's really, really important that patients follow those eye drop treatment regimens. I like to say to my patients, "This eye drop is a very powerful way to lower eye pressure, but it does not work if it is sitting in the bottle. It needs to go into your eye." There are a lot of different types of eye drops that we prescribe, and so the regimens can vary quite a bit.

I would say the most simple one would be a once a day eye drop that you might use at bedtime. But sometimes, we have patients on three or even four eye drop medications. Some of them need to be dosed two or even three times per day, and it's quite a feat getting them all in at the right times. But it's really quite important. Those eye drops lower eye pressure for a certain amount of time after they're instilled, and then that eye pressure will go back up once that eye drop medication has worn off. So that next dose is timed to really maintain that lower eye pressure. And we think that maintaining a lower eye pressure and really keeping it low without those kind of big fluctuations can really help protect the optic nerve, help preserve that sight.

The biggest misapprehension about glaucoma treatment I would say is about the effects of treatment. Most people expect that glaucoma eye drops will make their eyes feel better or help them to see better, but that really isn't the case. Eye drops for glaucoma help to lower the eye pressure to prevent future vision loss, so they help keep your vision, but they don't make vision better. And they can have some side effects. Most of them are manageable. People do great on their drops, but there can be some stinging or redness and sometimes, we do need to even stop or change drops because of side effects. So that misapprehension about the effects of treatment, that's one that I'd like people to know about too.

Ricky Enger: Thank you, Dr. Rosdahl, for giving us such a great overview of not only what glaucoma is and how it’s diagnosed, but also what to expect when it comes to treatment. Knowledge is power, right?

So, I guess, when it comes to eye conditions, there’s one part of the eye that gets mentioned quite a bit, for a number of reasons. So many eye conditions affect the retina, so we wanted someone to talk about that. What is the retina? What does it do? And what options do you have when something goes wrong with it? Well, who better to answer those questions than a retina specialist, so we approached Dr. Tim Murray to talk about that.

Dr. Tim Murray: I think the retina is the key to the vision that we enjoy. And for us that are a little bit older, the retina is much like the film in the camera. You know that light comes into the eye. It gets focused through the clear cornea and the lens which allows us to focus the image. But what actually takes that image and transfers it in an electrical way to our brain so that we can see is the retina. So, if the retina doesn’t function, you cannot see. For most retina specialists, we’re referral-based, which means that you've seen an optometrist or another ophthalmologist that has seen you and recognized that you have a retina specialty problem and has referred you. And most of those referrals are actually quite urgent. So, they may see a tear in the retina or a detachment, or tumor, or evidence of a stroke, or bleeding from diabetes. So, most of our patients, when they're made aware that they need a retina specialist need one quickly. A lot of times we have conditions that run in families. And so, we know that a family member may have a parent or a child or sibling that could have disease, and we'll actually, as the retina specialist, ask them to bring their family members in to be seen.

Ricky Enger: One of the most common diseases affecting the retina, especially in older individuals, is macular degeneration. And people who have been diagnosed naturally have a lot of questions about it, like what treatment options are available, and what’s likely to happen once they’ve been diagnosed.

Dr. Tim Murray: First of all, the most important thing is to recognize that most types of macular degeneration, which is the dry type of macular degeneration, never need to be injected. So, it's very important to get the correct diagnosis, as you might imagine. And the technology to do that has become incredibly precise. We have technology now that's called OCT, or Optical Coherence Tomography. It takes a laser scan of the retina that is so precise, it's better than what I used to see in the microscope when I was in medical school.

And those testing evaluations allow us to be incredibly precise about how we treat the patient. And at this point, we really personalize our therapy. So, it is not one size fits all. Every patient gets personally identified and targeted treatment based on how they're responding. Some patients are blessed and may need one injection only and never need to be injected again, and some patients need to be injected for their lifetime. But having said that it's worth it to do it well. Because before these injections, and I'm a little bit more mature, every person that we took care of with wet macular degeneration went blind. I almost never see that. And when I do see that it's because somebody came late, or for some reason, they weren't able to continue to be treated. So that's an amazing change, even in the last 10 years.

So that's the most important message to get across is that these conditions that routinely were blinding in our grandparents' decade are now very treatable and the key to that is early diagnosis and seeing a specialist that's equipped to take the best care of the patient.

Ricky Enger: There are actually two types of macular degeneration, so what if you’ve been diagnosed with dry macular degeneration? Do you have to still be seen by a retinal specialist, and if you do, how often does that need to happen?

Dr. Tim Murray: The reason why you want to be followed with dry macular degeneration is because it can convert from dry to wet, and wet is incredibly treatable and wet is typically the type of macular degeneration that leads to blindness. Dry macular degeneration usually doesn't have a significant impact in the visual function of the patient unless they develop what's called geographic atrophy. And that's literally where the retinal tissues in the center just become dysfunctional and they essentially wither away. Fortunately, that's a very rare component of macular degeneration. So, I think the last thing you want to do as a patient, when you have a condition that we know has long-term issues, is not to continue to be seen.

Ricky Enger: It’s interesting because a lot of people, regardless of their eye condition, end up having cataracts. So of course, they get cataract surgery to deal with that, and then the vision should be way better after that, right? Well, sometimes when a cataract is removed, a specialist can see more about what’s going on in the eye now that the view isn’t blocked by that cataract. So what happens at that point?

Dr. Tim Murray: One of the things that we try to teach our colleagues that are going to do cataract surgery is that it really is critical in this day and age to look at the macula with imaging before cataract surgery. Because if a patient has preexisting macular degeneration and that is the reason that the vision is being impacted, taking the cataract out is only going to unmask the macular degeneration. So, I think it's fair to counsel patients ahead of time by looking at the macula to say, "Look, we're going to take your cataract out, but you have macular degeneration, and it may require additional treatment by a retina specialist."

If you have your cataract removed and for any reason there is not a really good outcome visually, I think every one of those patients should see a retina specialist. Because many of the conditions that limit vision after cataract surgery are eminently treatable by a retina specialist.

Ricky Enger: Thank you, Dr. Murray. That information is so helpful for anybody with a retinal eye condition, and especially for those with mac d. It’s great to know what to expect. Now we’ve talked a lot about particular eye diseases and how they’re treated, but what we haven’t really talked about yet is what happens in addition to any medical treatment you get. You still have to figure out things like glasses, lighting, that kind of thing. And honestly, it’s hard to even know what’s available, as far as what can really help you get the most out of your remaining vision. And that’s where a low vision specialist can really make a difference. We talked with Dr. Mark Wilkinson about what you can expect when you walk into an appointment with a low vision specialist.

Mark Wilkinson: We want to know what the person's visual history is, what they've been told about their vision, their diagnosis, prognosis, what types of tools they've tried or have used in the past and what difficulties they're having at this point accomplishing the visual tasks that they need to do on a daily basis.

From there, we're going to assess their vision, both their distance and their reading vision, oftentimes a little bit different than might be done by their medical eyecare provider. We're going to double check their glasses prescription, which many times has not been done for a number of years, see if an alternate glasses prescription will help distance and/or reading vision.

We're going to review their contrast needs because contrast is very, very important for being able to function better. The real world is not perfectly black and white. And so that's one of the things I always tell people, is the eye exam room is the most unnatural place you can be because it's perfect lighting, perfect contrast, and the real world is not like that. From there, we'll review devices and strategies that can enhance the remaining visual abilities and allow them to do the things they're currently finding difficult or impossible to do.

I think that care is always ongoing, but that said, not everybody needs to be seen every few months or even every year. And I tell my patients if you don't have to see me, that's a good thing because it means your vision is stable and you're doing well with the devices you have. But with that in mind, I have a plan that I set up with each patient so that we know when we're going to see them again based on their individual needs and situations. And we always tell them you can come back and see me sooner if needed.

So, I don't necessarily have to see somebody on a regular basis, but certainly we're available. For instance, if they're having issues with driving or something, we'll have to see them on a more regular basis for that, or if they have some progressive condition. It also depends on their age. So, lots of variables, but definitely it's not a one-shot deal.

Ricky Enger: It sounds like one of the key things that a low vision specialist does is to develop a plan for how to approach things in a successful way, just by helping to figure out what tools are going to work best in a person’s daily life. So how can you prepare for a discussion like that?

Mark Wilkinson: I often times have to tell people your vision has been compromised, and because of that compromise, we're going to have to do things in a little bit different way. And so, there isn't a sort of a magic pair of glasses that's going to restore your vision back to the level that it was in the past. We're going to have to do things differently, which might mean holding things closer with a stronger pair of reading glasses. It might be holding a device. It might be using reverse contrast, the dark mode on your smartphone, or using some sort of video magnification device or increasing the magnification on your Kindle or your iPad. So, we're going to have to do things in a little bit different way, but when we do that, most often we can accomplish the goals and the tasks that you're still wanting to do.

I think that it's very important that they bring the devices they've been using so we can see what they've worked with, see what has worked for them, maybe worked well in the past, and then from there, determine what's going to be the best options for them.

Oftentimes people are buying things online, are mislabeled, and so they'll say, "Well, I'm using a 6X," and actually it's a six diopter, which is 1.5X. And so, seeing the devices that they've been using, what they've been successful with and what has not worked for them is very important.

I always remember my grandmother who had diabetic retinopathy, somebody would send her a new magnifier for Mother's Day and Easter and stuff, and she just looked at it and put it in a drawer and never used them. So, there's a lot of things that sound good by the advertising, but don't work because they're not really prescription devices.

Ricky Enger: I think that description of this drawer full of magnification devices sounds pretty relatable, pretty familiar to a lot of people. So, what should you expect a magnification device to be able to do? Do you have to get a different device for each task you’re doing, or is it possible to get a lot of general functionality with just one thing?

Mark Wilkinson: Many people can do well with one device. If they have mild vision loss, they may just need some stronger reading glasses. Other people who need electronic magnification may have a full-size video magnifier. They may have a portable one that they take with them when they're away from home. Now we have different apps that you can use and make your smartphone work like a video magnifier. You can have your smartphone read materials with text to speech.

And so, you have lots of options that are available, and it just really depends on what the person's having difficulty with. They might want to read, do hand work, but they also might want to play the piano. And so, they would need different devices for those different things. So, it really comes down to what the person wants to do, and then the different tools that will help them to do that.

Ricky Enger: Thank you, Dr. Wilkinson, for sharing just how important a low vision specialist can be for helping you to figure out how to get back to doing the things you love just by learning about some devices and tools that can help you use your remaining vision effectively.

We really do appreciate all the experts who have shared their time and their valuable knowledge with us. If you want to learn more about anything we’ve shared in today’s episode, including the full interviews with each of our guests from today, you can check out the show notes for links to lots of great resources. Also, Hadley is available to answer questions and help you find information, so yeah, you can give us a call. That’s 800-323-4238, and it can help to just have a conversation about some of this stuff, like what to expect at the eye doctor, or how to find a low vision specialist, you know, what magnification devices are out there, all those things we’re happy to talk through with you. Thanks again to our guests for spending some time and sharing their knowledge with us and thank you so much for listening!

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