Review Category : Dr. Mark Siegel, MD FAAO

Melanoma of the eye

By Dr. Mark S. Siegel

Malignant “choroidal” melanomas arise from the blood-vessel layer “choroid” beneath the retina. In North America, 6 out of each million people will be diagnosed with a choroidal melanoma each year. Malignant choroidal melanomas can spread to other parts of the body.

Ophthalmologists can determine if you have a choroidal melanoma by performing a complete eye examination. This includes asking questions about your medical history, examining both of your eyes, looking into the eye through a dilated pupil at the tumor, performing an ultrasound examination, and specialized photography (to examine the circulation within the choroidal melanoma). HEALTH - melanomas

Your ophthalmologist will also request that you have a complete general medical check up and specific tests depending upon what they see inside your eye. Ophthalmologists can correctly diagnose an intraocular choroidal melanoma in over 96% of cases (without a biopsy). Though occasionally necessary, biopsies can be avoided because they require opening the eye (which risks letting choroidal melanoma cells out) and risk intraocular hemorrhage and infection.

Symptoms

Most patients with choroidal melanoma have no symptoms and the melanoma is found on routine eye examination. If patients have choroidal melanoma symptoms, they are usually seeing “flashes of light,” noticing “distortion” or loss of vision, and floating objects (floaters) in their vision.

1) If the choroidal melanoma is in the front of the eye (near the natural lens), it can push or tilt the natural lens causing an irregular astigmatism (blurring of vision).

2) Choroidal melanoma can leak fluid beneath the retina, making the retina detach and cause symptoms of flashing lights and floating specks.

3) If the choroidal melanoma is in the macula (center of vision), it can grow beneath the fovea making the patient far-sighted. The choroidal melanoma can also grow into and destroy the fovea causing distortion, loss of vision or changes in color perception.

It is important to note that most patients with choroidal melanoma have no symptoms at all. Their tumors are found when they visit their eye doctor for a “routine” eye examination. So everyone should have at least an annual eye examination (includingdilated ophthalmoscopy).

Other, more unusual presentations of anterior choroidal (iris) melanoma are discoloration of the iris, a brown spot on the outside of the eye, an irregularly shaped pupil and glaucoma.

Treatment

Small Choroidal Melanoma:
Patients with a small choroidal melanoma can be treated after their first visit, but since growth helps to prove that the tumor is a cancer, your doctor may suggest “observation” or watching for a small amount of choroidal melanoma growth prior to treatment. Your ophthalmologist should discuss the relative risks and potential benefits of  “observation for growth” as compared to “immediate treatment” for choroidal melanoma. Once growth is documented, your ophthalmologist will recommend definitive treatment.

Medium-sized Choroidal Melanoma:
Around the world, most patients with a medium-sized choroidal melanoma are treated with either radiation therapy or removal of the eye. Though there are several forms of eye and vision-sparing radiation therapy, ophthalmic plaque radiation therapy is the most common and widely used.

Since the results of the Collaborative Ocular Melanoma Study (COMS) suggest that plaque radiation therapy and enucleation of the eye are equally effective for the prevention of metastatic choroidal melanoma, few patients with medium-sized choroidal melanoma are treated by removal of the eye.

Because both enucleation and plaque radiation therapy for choroidal melanoma are likely to harm your vision (in that eye), you should discuss the risks and benefits of these and other treatment options in consultation with your ophthalmologist.

Large-sized Choroidal Melanoma:
A patient with a very large choroidal melanoma may be treated by removal of the eye (enucleation). This is because the amount of radiation required to destroy a choroidal melanoma that fills most of the eye may be too much for the eye
to tolerate.

However, most patients with large-sized choroidal melanoma can also be treated with eye-sparing radiation therapy. After radiation for large choroidal melanoma, these eyes are at greater risk to have poor vision, to become uncomfortable and may have to be secondarily removed.

It is important to note that as compared to like-sized malignant melanoma of the skin, patients are much more likely to survive a choroidal melanoma. This is because it is much more difficult for a choroidal melanoma to spread from (get out of) the eye to other parts of the body. However, large (choroidal melanoma) tumor size decreases the chance that vision-sparing treatments will be successful. In general, the larger the choroidal melanoma the worse the prognosis for both vision
and metastasis.

Patients often ask why they have a choroidal melanoma. Choroidal melanoma is more common among patients with blue vs. brown eyes, those with outdoor occupations and in Australia where there is an ozone hole. Therefore, it seems reasonable to assume (though unproven) that choroidal melanoma is related to sunlight (ultraviolet exposure).

Because sunlight exposure has been linked to several eye cancers and diseases of the eye, I suggest that you think of Sunglasses as Sun Block for your Eyes and start wearing your UV blocking sunglasses. They make great gifts too!

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A cup of coffee a day may keep retinal degeneration away!

By Dr. Mark S. Siegel

Here’s something coffee drinkers can get excited about. Aside from java’s energy jolt, food scientists say you may reap another health benefit from a daily cup of joe: prevention of deteriorating eyesight and possible blindness from retinal degeneration due to glaucoma, age-related macular degeneration and diabetes.

Raw coffee is, on average, just 1 percent caffeine, but it contains 7 to 9 percent chlorogenic acid (CLA), a strong antioxidant that prevents retinal degeneration in mice, according to a Cornell study published in the Journal of Agricultural and Food Chemistry (December 2013).

The retina is a thin tissue layer on the inside, back wall of the eye with millions of light-sensitive cells and other nerve cells that receive and organize visual information. It is also one of the most metabolically active tissues, demanding high levels of oxygen and making it prone to oxidative stress. The lack of oxygen and production of free radicals leads to tissue damage and loss of sight.

In the study, mice eyes were treated with nitric oxide, which creates oxidative stress and free radicals, leading to retinal degeneration, but mice pretreated with CLA developed no retinal damage.

The study is “important in understanding functional foods, that is, natural foods that provide beneficial health effects,” said Chang Y. Lee, professor of food science and the study’s senior author. Lee’s lab has been working with Sang Hoon Jung, a researcher at the Functional Food Center of the Korea Institute of Science and Technology in South Korea. “Coffee is the most popular drink in the world, and we are understanding what benefit we can get from that,” Lee said.

Previous studies have shown that coffee also cuts the risk of such chronic diseases as Parkinson’s, prostate cancer, diabetes, Alzheimer’s and age-related cognitive declines.

Since scientists know that CLA and its metabolites are absorbed in the human digestive system, the next step for this research is to determine whether drinking coffee facilitates CLA to cross a membrane known as the blood-retinal barrier. If drinking coffee proves to deliver CLA directly into the retina, doctors may one day recommend an appropriate brew to prevent retinal damage. Also, if future studies further prove CLA’s efficacy, then synthetic compounds could also be developed and delivered with eye drops.

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February is National AMD/Low Vision Awareness Month

By Mark S. Siegel

AMD or Age-Related Macular degeneration is the leading cause of vision loss affecting over 15 million adults over the age of 50. To understand how AMD affects your vision, place your left hand over your left eye. Now make a fist with your right hand. Take your right fist and place it directly in front of your right eye. The only thing you should see is images in your periphery or side vision. Now imagine that this is how you are to function within the world.

AMD

Age-Related Macular degeneration can develop so slowly that it’s not until the vision is severely affected that the patient will notice. Age-Related Macular Degeneration primarily destroys the sharp central vision controlled by a spot at the back of the retina called the macula. Sharp central vision is needed to read, drive, identify faces, watch television and perform daily tasks that require straight ahead vision.

Risk Factors

The exact cause of AMD is not known. There are a number of risk factors that may play a role, some you can help control, and some you cannot. The same risks factors for heart disease and stroke also increase your risk for AMD. These include:

  • High blood pressure
  • High cholesterol
  • Obesity
  • Smoking

Risks you cannot control include age, family history, gender and race.

Symptoms

AMD symptoms include blurriness, wavy lines, or a blind spot. You may also notice visual distortions such as:

  • Straight lines or faces appearing wavy
  • Doorways seeming crooked
  • Objects appearing smaller or farther away

If you notice any of these symptoms, you should see an ophthalmologist as soon as possible. If you are diagnosed with wet AMD, it is important to see a Retina Specialist for the most appropriate care.

Living with AMD

Make the most of your Vision. Millions of people have macular degeneration and millions of them continue to do everything they always did. Because you never become completely blind with AMD, there is always sight available if you know how to use it.

The peripheral vision you have helps you to get around the house and outside. There are devices and techniques for everything from reading to cooking to watching sports on TV. You may have to stop driving at some point, but for everything else, there is a solution.

If you are losing sight, there are some simple things you can do on your own to improve your ability to see. Don’t become discouraged! You will probably need to try out multiple devices before you find one that works for you. These range from magnifiers that are held in the hand or suspended on a stand to devices that attach to your glasses or computers that help you to read.

Things you can do on your own:

  • Improve the lighting in your home and office. This may not necessarily mean that you should increase the lighting or the brightness. Glare is often a problem for people with low vision. You’ll need to experiment to see what works best for you. Special lights are available through many catalogs.
  • Use a high contrast for reading and writing. Write in large letters with a broad felt tip pen on white or light paper.
  • Use large print books, I-pads or tablets to increase the font size and contrast or try other media, like audio books. Most libraries have a section of these or you can find them online. There are also special libraries for visually impaired.
  • Use a hand held magnifier. In the beginning, you may find some help at your local drug store by trying out the various small hand-held magnifiers available. If one of them helps your vision, you should certainly use it. Other magnifying devices may be more useful if your vision is very poor.

So see your eye doctor regularly for early detection of AMD!

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What’s in your eye vitamins?

By Mark S. Siegel

Americans spend billions of dollars each year on vitamins, some of which are eye vitamins. But not all of these products have the ingredients and dosages that have been proven effective in clinical trials.

Researchers have analyzed popular eye vitamins to determine whether their formulas and claims are consistent with scientific findings. They found that some of the top-selling products do not contain identical ingredient dosages to eye vitamin formulas proven effective in clinical trials. In addition, the study found that claims made on the products’ promotional materials lack scientific evidence.

The leading cause of blindness among older adults in the United States is age-related macular degeneration (AMD). A specific formula of nutritional supplements is recommended for AMD treatment when the disease is at certain stages. This is based on two landmark clinical trials known as AREDS and AREDS2. These studies found that high doses of antioxidants and zinc could slow the worsening of AMD in those who have intermediate AMD and those with advanced AMD in only one eye.

The first study included beta-carotene in its formula but, due to beta-carotene’s link to increased risk of lung cancer in smokers, this was replaced with related nutrients lutein and zeaxanthin. The two studies prompted a surge in sales of eye supplements that are marketed as containing the AREDS or AREDS2 formulas. To test whether the products are consistent with the studies’ findings, researchers compared the ingredients in 11 products from the five top-selling brands to the exact formulas proven effective by AREDS and AREDS2. They found that, while all of the products studied contained the ingredients from the AREDS or AREDS2 formulas:

•   Only four of the products had equivalent doses of AREDS or AREDS2 ingredients
•   Another four of the products contained lower doses of all the AREDS or AREDS2 ingredients
•   Four of the products also included additional vitamins, minerals and herbal extracts that are not part of the AREDS or AREDS2 formulas

All 11 of the products’ promotional materials contained claims that the supplements “support,” “protect,” “help” or “promote” vision and eye health, but none had statements specifying that nutritional supplements have only been proven effective in people with specific stages of AMD. There were also no statements clarifying that there is insufficient evidence to support the routine use of nutritional supplements for primary prevention of eye diseases such as AMD and cataracts.

People considering taking eye vitamins should talk with their ophthalmologist about whether these nutritional supplements are right for them. Those who are already taking eye vitamins should compare the ingredients with the AREDS and AREDS2 formulas, below.

AREDS
•   Vitamin C – 500 mg
•   Vitamin E – 400 IU
•   Zinc (zinc oxide) – 80 mg
•   Copper (cupric oxide) – 2 mg
•   Beta-carotene – 15 mg

AREDS2
•   Vitamin C – 500 mg
•   Vitamin E – 400 IU
•   Zinc (zinc oxide) – 80 mg
•   Copper (cupric oxide) – 2 mg
•   Lutein – 10 mg
•   Zeaxathin – 2 mg

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Choose safe toys this holiday season

By Mark S. Siegel

No one chooses gifts with the intent to harm, but some popular children’s toys can cause serious injuries.

According to the U.S. Consumer Product Safety Commission, nearly 257,000 toy-related injuries were treated in emergency rooms in 2013, and almost half of these injuries affect the head or face. In fact, about 1 in 10 children’s eye injuries treated in the ER trace back to toys. Unfortunately, most of these injuries happen to children under age 15.

“You’ll shoot your eye out”

Some propelling toys, like airsoft guns, arrows, BB guns, paintball guns and darts can be particularly hazardous, with the potential to cause serious eye injuries such as corneal abrasion, hyphema (bleeding inside the eye), traumatic cataract, increased intraocular pressure and even permanent vision loss.

The good news is that following a few toy safety tips can easily prevent most eye injuries.

Top Toy Safety Tips:

• Avoid purchasing toys with sharp, protruding or projectile parts.

• Make sure children have appropriate supervision when playing with potentially hazardous toys or games that could cause an eye injury.

• Ensure that laser product labels include a statement that the device complies with 21 CFR (the Code of Federal Regulations) Subchapter J.

• Along with sports equipment, give children the appropriate protective eyewear with polycarbonate lenses. Check with your eye doctor to learn about protective gear recommended for your child’s sport.

• Check labels for age recommendations and be sure to select gifts that are appropriate for a child’s age and maturity.

• Keep toys that are made for older children away from younger children.

• If your child experiences an eye injury from a toy, seek immediate medical attention.

Have a safe and happy holiday!

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Maintain eye health with diabetes

By Mark S. Siegel

Diabetes is a disease that affects the body’s ability to produce or use insulin effectively to control blood sugar (glucose) levels. Although glucose is an important source of energy for the body’s cells, too much glucose in the blood for a long time can cause damage in many parts of the body, including the heart, kidneys, blood vessels and the small blood vessels in the eyes.

When the blood vessels in the eye’s retina (the light sensitive tissue lining the back of the eye) swell, leak or close off completely — or if abnormal new blood vessels grow on the surface of the retina — it is called diabetic retinopathy.

People who are at greater risk of developing diabetic retinopathy are those who have diabetes or poor blood sugar control, women who are pregnant, and people with high blood pressure, high blood lipids or both. Also, people who are from certain ethnic groups, such as African-Americans, Hispanics and Native Americans, are more likely to develop diabetic retinopathy. In fact, a new study confirms that diabetes is a top risk factor for vision loss among Hispanics.

Something to remember: diabetes can cause vision in your eyes to change even if you do not have retinopathy. If your blood sugar levels change quickly, it can affect the shape of your eye’s lens, causing blurry vision, which goes back to normal after your blood sugar stabilizes. Therefore, it’s important not to change your glasses prescription unless your blood sugar levels are normal.

Did you know there is also a link between diabetes and cataracts? Permanent blurring of vision due to cataracts can also result from changes to the lens due to excess blood sugar. Cataract surgery may be necessary to remove lenses that are clouded by the effects of diabetes and replace them with clear intraocular lenses (IOLs) to restore clear vision.

Maintaining good control of your blood sugar helps reduce episodes of temporary blurred vision and prevent the permanent clouding of the lens that would require surgery to correct.

Mark Siegel,  MD, FAAO, Medical Director, Sea Island Ophthalmology, www.seaislandophthalmology.com

 
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Study: Hip fractures less likely after cataract surgery

By Dr. Mark S. Siegel

After practicing ophthalmology for nearly 15 years and performing thousands of cataract surgeries, I’ve recognized additional benefits beyond better vision and spectacle independence: patients improve their ability to ambulate; cognitive function and mood are improved in patients with dementia and depression; and overall quality of life improves.

When older people have cataract surgery to improve their vision, they also lower their risk of falling and breaking a hip, according to a national study. People in their 80s and those who have serious illnesses such as heart disease are most likely to benefit — the research shows that these patients had about 30 percent fewer hip fractures in the year after they had cataract surgery. The study, published in the August edition of the Journal of the American Medical Association, compared the rate of hip fractures in more than 400,000 Medicare patients who had cataract surgery with a matched group of patients who did not have their cataracts removed.

Older people are more likely to fall and break their hips or other bones, and recovering from such injuries is often difficult for them. Earlier studies have found that vision loss is a key reason for seniors’ higher risk of falling. When cataracts and other aging eye problems decrease older people’s visual sharpness and depth perception, they also lose the ability to maintain balance, stability and mobility.

People should never be regarded as “too old” to have their cataracts removed. Other studies show that after cataract surgery, older people tend to sleep better, be less depressed, and lead more active, enjoyable lives.

Overall, the greatest decrease in hip fracture risk was seen in patients aged 80 to 84 who had cataract surgery. Another notable group was patients with severe cataracts, for whom risk was reduced by 23 percent. Although U.S. health statistics show that women are more susceptible to hip fractures than men, this study found no significant gender-linked differences in fracture risk.

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Sleeping in contact lenses is a risky endeavor

By Mark S. Siegel

If you’re a contact lens wearer, chances are you’ve snoozed with your contacts in at least a time or two. Maybe you only do it once in awhile, when you fall asleep in front of the TV or forget to bring disinfecting solution on an overnight trip. Or maybe it’s more of a regular practice, and you leave them in for days (and nights) at a time.

Either way, it’s not a good idea.

When you sleep with your contact lenses in, you’re depriving your corneas of oxygen. This is analogous to wearing a plastic bag over your head when you sleep which is not ideal for oxygen exchange. The cornea receives oxygen from the air when you are awake, but when you are asleep, it gets nourishment and lubrication from tears and a gelatinous fluid inside the eye called the aqueous humor. If there’s a contact lens in your eye when you’re sleeping, then the contact lens acts as a barrier between the closed eyelid and the cornea, and it’s fairly tight over the surface of the cornea. When you’re awake, the contact lens is actually supposed to move a bit — about a millimeter of movement with every blink — in order to allow the cornea to get oxygen. But when you’re sleeping with your contacts in, the contact lens is unable to move because your eyes aren’t blinking. The end result is an oxygen-starved cornea, which becomes more susceptible to infection.

Bacteria or parasites can infect any microscopic abrasions of the cornea, which can be caused by contact with the back surface of the contact lenses. These bacterial microorganisms are part of our normal eyelid flora or can be introduced from the contact lenses themselves (a contact lens can have some bacteria on it because it’s not clean or it’s been resting on the eyes for so long), or from water, even when it’s safe for drinking. A parasite found in water called acanthamoeba, for example, can cause serious eye infections. Corneal ulcers, which are localized infections of the cornea, may cause permanent scarring resulting in loss of vision or even blindness.

In fact, a 2012 study in the journal Ophthalmology showed that the risk for keratitis — inflammation of the cornea — increased 6.5 times with just occasional overnight lens use among people who used contact lenses intended for removal at the end of the day.

While there are some contact lenses that have been FDA-approved for “extended wear,” meaning you can wear them for multiple days at a time, the FDA still recommends people using these lenses remove them and not wear them overnight at least one time a week. However, it’s simply not a good idea to wear these lenses overnight, if you can help it, because there is still an increased risk for infection.

Moreover, multiple studies have shown that people who wear extended-wear lenses (soft hydrogel lenses) have a 10 to 15 times higher risk of developing ulcerative keratitis, compared with daily-wear contact lens users. Overnight wear, regardless of contact lens type, increases the likelihood of corneal infection, which may result in permanent vision loss or even blindness and should be avoided.

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The benefits of exercise and alcohol

By Dr. Mark S. Siegel

In 2020, the number of people in the United States with visual impairment – sight loss often caused by eye disease, trauma, or a congenital or degenerative condition that cannot be corrected with glasses or contact lenses – is projected to increase to at least four million. This is a 70 percent increase from 2000 and is due to the growing aging population and prevalence of age-related eye diseases.

To help determine ways to decrease the incidence of visual impairment, researchers at the University of Wisconsin examined the relationships between the incidence of visual impairment and three modifiable lifestyle behaviors: smoking, drinking alcohol and staying physically active. The research was conducted as part of the Beaver Dam Eye Study, a long-term population-based cohort study from 1988 to 2013 of nearly 5,000 adults aged 43 to 84 years.

The researchers found that regular physical activity and an alcoholic beverage every now and then is associated with a lower risk of visual impairment. The data showed that over 20 years, visual impairment developed in 5.4 percent of the population and varied based on lifestyle behaviors. For example, people who were physically active had a 58 percent decrease in the odds of developing visual impairment compared to people who were not physically active.

The researchers also found that people who drank alcohol occasionally (defined as those who have consumed alcohol in the past year, but reported fewer than one serving in an average week) had a 49 percent decrease in the odds of developing visual impairment compared to people who had consumed no alcohol in the past year.

As with most epidemiologic research, the researchers caution that a limitation to their study is that the findings may be due, in part, to unmeasured factors related to both lifestyle behaviors and development of visual impairment. The data does not prove that these lifestyle behaviors are directly responsible for increased risk. The researchers still believe the research shows good promise for indicating ways that people can lessen their risk of visual impairment through lifestyle changes.

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Leave fireworks to professionals this Fourth of July

By Dr. Mark S. Siegel

I recall a few extraordinary patients during my ophthalmology residency who have left an indelible memory. One such patient was a 13 year old who was playing with an M-80 explosive device that he placed in a soup can. The subsequent explosion sent shards of metal that were absorbed by his face and one of his eyes. The metal perforated his cornea and lens and lodged in the back wall of his eye in his retina. After multiple surgeries, he can see a hand waved in front of his face.

I really hate to be a buzz kill before this Fourth of July holiday — what should be a time when wonderful memories are made with family and loved ones.

Unfortunately, more than 9,000 fireworks injuries happen each year on average in the United States, with roughly 1 in 8 fireworks injuries harming the eyes, according to the most recent fireworks injury report from the U.S. Consumer Product Safety Commission. Common fireworks eye injuries include burns, lacerations, abrasions, retinal detachment, optic nerve damage and ruptured eyeballs.

Those injured are not necessarily handling the explosives themselves. In fact, nearly half of people injured by fireworks are bystanders, according to an international study. Children are frequent victims: 30 percent who sustained a fireworks injury near the Fourth of July holiday are ages 15 and under, according to the commission report.

Even sparklers can burn more than 1,000 degrees hotter than the boiling point of water. So, fireworks should not be thought of as toys, but devices that can cause third-degree burns. This is why people must be vigilant and take precautions to avoid the risk of serious eye injury.

Fireworks Safety Tips

The best way to avoid a potentially blinding fireworks injury is by attending a professional public fireworks show rather than purchasing fireworks for home use.

For those who attend professional fireworks displays and/or live in communities surrounding the shows:

• Respect safety barriers at fireworks shows and view fireworks from at least 500 feet away.

• Do not touch unexploded fireworks; instead, immediately contact local fire or police departments to help.

For those who decide to purchase consumer fireworks because they live in states where they are legal, such as South Carolina, follow the following safety tips to prevent eye injuries:

• Never let children play with fireworks of any type, even sparklers.

• Adults handling fireworks should always wear protective eyewear that meets the parameters set by the American National Standards Institute and ensure that all bystanders are also wearing eye protection.

• Leave the lighting of professional-grade fireworks to trained pyro technicians.

Remember, if an eye injury from fireworks occurs, seek medical attention immediately.

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