Getting Back to the Basics

For the past several weeks this blog has been all over the map: health policy, adult education, surgical drapes, brain cancer.

'Umm, excuse me. Isn't this blog supposed to be about the eyes and visual health?"

Time to get back on topic - for awhile anyway!

Quite a few visitors to our WebMD Vision & Eye Disorders Message Board post inquiries about worrisome symptoms and wonder when is the right time to find an eye doctor.

Sometimes the symptoms sound quite benign: I see little specks when staring at fireworks; should I make an eye appointment?

There are other times when my jaw drops: I lost sight in my left eye three days ago; what should I do?

Since WebMD does not diagnose members' health problems, manage their diseases or make treatment recommendations, it is tempting to respond with authority and indifference, "Go away, you've come to the wrong place for help!" The reality is that the health professionals at WebMD devote so much time online because they like helping people in need by providing reliable information.

So, when should you contact your doctor about an eye problem?

Here's a handy checklist to consult whenever you sense something about your eyes is just not right - whether it involves one or both eyes:

• Sudden change in vision


• Loss of visual field (grey or black curtain)


• Eye pain


• Progressive redness or copious discharge (especially in contact lens wearers)


• Severe or persistent headache


• Accidental eye exposure to toxic substances (chemical splash)


• Any discomfort following surgery that remains after taking the prescribed pain medication


• Eye or orbital trauma - even if the eye looks okay


• Intense light sensitivity


• Swelling or tenderness of the eyelids and periorbital skin


• Sudden, persistent double vision


• Facial shingles (herpes zoster)


• Nonreactive pupil


• New onset droopy eyelid

This list is not all-inclusive, but the above situations warrant prompt referral to an experienced eye doctor. If you are smart you already have an eye doctor you trust. Otherwise, you may need a referral from your primary care provider or seek care at a nearby emergency room that has ophthalmology coverage.

Here's one final precaution. So often I read messages that express hesitancy to bother the eye doctor. Baloney! The doctor went to school and trained all those years in order to become available for bothering. Doctors who are rarely bothered have very few patients - it's how the system works. If it turns out that no dire emergency has occurred you will both breath a huge sigh of relief.

We encourage everyone to continue posting to our message board. Just keep in mind that, sometimes, the best information we can provide is "Stop surfing and go get yourself some help!"

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• Eye Health: Choosing an Eye Doctor
• WebMD Eye Heath Center

Technorati Tags: vision, eye health

Sudden Headache: Think Elsewhere

Buried beneath all of the headlines concerning Senator Edward M. Kennedy's brain tumor diagnosis is an equally important story with valuable health advice for everyone.

Remember New York's new Governor, David Patterson? He succeeded Eliot Spitzer after 'Client 9' resigned because of his involvement with prostitutes. Patterson also gained attention for becoming New York's first black governor and for being America's first legally blind governor.

Governor Patterson is blind in his left eye and has very limited vision in the fellow eye.

Earlier this week Governor Patterson went to the hospital complaining of severe left-sided headache. The original symptoms suggested migraine: intense pain, one sided, worse with physical exertion, nausea. Patterson was admitted for evaluation but all of the migraine testing was negative.

The facts are incomplete but it appears that someone decided to perform an eye exam and, lo and behold, Patterson was found to have a dangerous elevation of intraocular pressure in the blind left eye. Yes, acute glaucoma was responsible for all of his misery.

Medications successfully lowered the pressure and a laser surgical procedure fixed the anatomic problem that allowed Patterson's pressure to jump so high.

Here's the point: many folks presenting with acute pain are experiencing an unrecognized glaucoma attack. People with 'the worst headache of their life' did not have a burst aneurysm or meningitis - they had an eye problem that generated enormous referred pain.

Beware! It's not just headaches, either. Folks have undergone appendectomy for abdominal pain and nausea...symptoms caused by an abrupt elevation of intraocular pressure.

Acute glaucoma can affect blind eyes as well as eyes that see 20/20. Although Governor Patterson had no sight in his left eye he was still able to sense pain. Other people in this same situation with an otherwise healthy eye need urgent care in order to correctly diagnose and treat the glaucoma. Time wasted leads to permanent, irreversible loss of the delicate nerve fibers that allow us to see.

Here's some solid advice for my physician colleagues and all other readers: if you ever have to accompany someone to the emergency room with new-onset severe pain (headache, belly pain, facial pain, dental pain...whatever!) and the treating doctor cannot identify the cause, consider the possibility of acute glaucoma. You might just save somebody's eyesight.

Related Topics:

• WebMD Video: Tiny Eye Implant Helps Treat People with Glaucoma
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Technorati Tags: glaucoma, headache, pain, blindness, Patterson, vision

Brain Tumor Caused Kennedy Seizure

Senator Edward M. Kennedy's physicians have announced that the seizure that led to Kennedy's recent hospitalization was caused by a malignant brain tumor.

Given that Senator Kennedy had not suffered a stroke, physicians everywhere were already suspicious that some kind of mass was responsible for the seizures. In medical circles it was a pretty big elephant in the middle of the room, but everyone wanted to be hopeful.

During the brain imaging that was performed on Saturday, radiologists quickly identified an abnormal growth involving the left parietal lobe - a region of the brain not far from the left ear. The parietal lobe is involved is many higher-order functions like vision and speech.

The level of sophistication in today's CT/MRI scanners is so good that the doctors at Massachusetts General Hospital likely knew immediately what type of tumor they were dealing with because of its location and because each different kind of cancerous growth generates specific imaging features. Confirmation of the tumor diagnosis was established with a brain biopsy. You're right, nobody mentioned brain biopsy over the weekend, did they?

Pathologists studied the biopsy specimen and called it a malignant glioma. You probably know what the first word means. The term 'glioma' indicates that the tumor is made up of glial cells. Most of the brain is made up of neurons - nerve tissue. Glial cells are the housekeepers. They have odd-sounding names like astrocytes, oligodendrocytes and microglia. Glia insulate the neurons, synthesize important proteins, and generate connective tissue that holds the brain tissue together. They also serve important immune functions for all kinds of nerves. It is glial cells that are replicating in an uncontrolled, malignant fashion; not neurons, not nerve tissue.

You may be asking yourself, "Why not just scoop-out the tumor like an avocado pit?" Believe me, if it were possible the Senator would already be in the recovery room. Glial cells are highly infiltrative, making complete resection extremely problematic. Also, since this mass is situated in an area responsible for such critical tasks, it may not be helpful to further compromise such precious neuroanatomy. Kennedy's doctors are talking about radiation and chemotherapy. Overall survivorship is poor but much can be done to help Senator Kennedy enjoy a quality life in what time remains. Given his age (76) nobody contemplates hyper-aggressive treatments that potentially risk shortening an already-threatened life.

The tumor size is not very relevant. A tiny pea-sized growth in the brainstem will kill you far quicker than a slowly-expanding potato in the peripheral cortex.

Involvement of the parietal lobe suggests that Senator Kennedy's visual fields may be affected. Similar patients often develop a homonymous hemianopia: loss of right field of view in both eyes. Radiation treatments may also contribute to field loss.

Now the real work begins. Senator Kennedy's tumor will be accurately staged with regards to its cellular features, degree of aggressiveness, and areas of involvement. Experts will discuss which specific treatment regimen offers him the most favorable outcome, not necessarily the longest life. Cycles of radiation treatment and chemotherapy will then begin with periodic re-evaluations to assess the effects of therapy and the patient's clinical response. During all of this, other health care team members will monitor Kennedy's nutrition, blood labwork, physical activity and neurologic performance.

It's too early to speculate as to whether of not Senator Kennedy will resign from office. It may not be necessary. Right now he is fully functional and enjoys a spectacular support system. Most Americans diagnosed with malignant glioma find the courage to keep on working for as long as they can. I would expect nothing less from this latest brain cancer victim.

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• 10 Important Questions to Ask Your Doctor About Brain Cancer
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Technorati Tags: Kennedy, brain tumor, brain cancer

Sidelined Senator Kennedy: Stroke or Seizure?

Much of the weekend's news coverage has been devoted to a health crisis involving Massachusetts' Senator Edward M. Kennedy. It appears that family members witnessed stroke-like behavior and called 9-1-1. The 76 year-old senator was promptly rushed to a community hospital in Cape Cod and evacuated by helicopter to Boston (Massachusetts General Hospital).

Medical experts who have evaluated Kennedy declared that the senator did not experience stroke, but instead he had sustained a seizure.

Sadly, many Americans automatically connect the words Kennedy and conspiracy: two assasinations, Teddy's plane crash, Chappaquiddick, William Kennedy Smith trial, JFK Jr.'s plane crash. Some folks are skeptical that any news item about the Kennedys is manipulated.

Once the news broke on Saturday a lot of TV viewers probably said to themselves, "I may not have graduated from medical school but I would know a seizure if I saw one!" Sure, but what if you didn't see the seizure? By that I mean, Senator Kennedy might have been alone when the seizure occurred and was not discovered until he was post-ictal (medical terminology for 'after the seizure').

After a seizure the victim may appear fatigued (lethargic), confused, and disoriented. They may not be able to speak clearly or ambulate without assistance. A first-time stroke can be even more dramatic because it is totally unsuspected. Those who observe post-ictal behavior could very easily assume that a stroke has happened. On top of that, Senator Kennedy's father suffered a massive stroke during JFK's presidency, so the family was sensitive to the problem.

Unlike stroke, a seizure by itself ought not to create any lingering neurologic deficits like limb weakness or loss of visual field. Time is precious if stroke is suspected, so it was very appropriate for the senator to receive such expeditious care. Hopefully it will be there for us, too, if we need it.

Senator Kennedy's health care team is very busy identifying possible causes of the seizure. Something as simple as dehydration or an undiagnosed infection could be responsible. An ophthalmologist has very likely been consulted because circulatory abnormalities that can lead to seizure (or stroke) can be directly visualized in the retinal blood vessels. The optic nerves are also studied for clues that might suggest elevated spinal fluid pressure. Visual field testing may even be performed to document that the complete visual cortex is receiving adequate oxygen. Many first-time seizures are idiopathic, meaning no specific underlying cause is identified. Nonetheless, a complete seizure workup will offer solid documentation for future comparison in case things deteriorate.

All of the preliminary reports have been very promising and the Senator's prognosis appears favorable. Despite the good news many Americans will withhold judgment until they see Senator Kennedy walk out of the hospital on his own without assistance. Time will tell.

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Geodesic Seizure Mapping for Epilepsy

First Aid for Seizures

Technorati Tags: Edward Kennedy, stroke, seizure, symptoms

Adult Learning: SEE What I Mean?

I read something very interesting the other night that I wanted to share with you.

Adults are different than children.

No, wait, there's more!

Adults learn differently than children.

Photo: Jason Taellious

Parents send their children to school to acquire the basic learning in order to function in society: language skills, arithmetic, spelling, etc. Things change as you get older. Adults don't have to go to school unless it is something they choose. The entire process of adult learning varies tremendously compared to what is experienced by children. It begins with motivation: adults seek more education in order to create change (involving skills, behavior, knowledge level, even attitudes). Previous experiences and the personal level of engagement also shape adult learning.

So, what does any of this have to do with vision, Doctor Lloyd?

Adult learning styles vary enormously from childhood learning patterns. Think about when you were in grade school. With few exceptions most elementary school classes were pretty much taught the same way.

Photo: Matt Biddulph

Lots of research has been performed on this topic and it appears that there are three major adult learning styles:

Visual learners (aha!) absorb new information by seeing it. They enjoy PowerPoint presentations, video demonstrations, and lots of illustrations in the reading materials. Use of computers in the adult classroom really stimulates visual learners. I have to admit that I enjoy dynamic lectures with lots of interesting images, graphics, and animations.

Listen to this - auditory learners prefer to hear the new material. They tend to recall verbal information far better than written material. In fact, they don't want to read anything. Perhaps this is why I often doze-off during sermons on Sunday mornings.

The final group of adult students are kinesthetic learners. These are the 'hands on' students - teach them by showing them what's important to know. My military career gave me enormous exposure to the time-honored technique: 'see one, do one, teach one'!

Successful adult educators know that adults learn best when classwork combines visual, auditory, and kinesthetic activities.

Do you see what I mean? Does this sound right to you? How do you feel about it?

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Technorati Tags: learning styles, adult education, visual, auditory, kinesthetic

What's the BIG IDEA?

I greatly admire innovators. Sure, discoverers and pioneers are daring and courageous because they seek something that appears unattainable (like the summit of Mt. Everest or a cure for pneumonia).

Innovators are different because they find a new way, a smarter way to do something that already exists. The iPod is an innovation that replaced tapes and CDs.

Surgeons can be great innovators, too, and the simplest tweaks often generate the most profound results.

Take surgical drapes as an example. These are large disposable sheets of plastic-lined paper that are used to create a sterile field in the operating room. Typically, the patient's body is totally covered in these sterile paper drapes - even for eye surgery. The surgical team wears gloves and gowns and all of the surgical equipment that enters the surgical field is also sterile.

There can be problems with paper drapes. They are big and bulky. They are relatively expensive. They are flammable. Yes, the surgical drapes can catch fire, and you'd be surprised how often fires erupt in the O.R. There are plenty of sparks, plenty of fuel, and lots of heat in a busy operating room. Surgical lasers are particularly dangerous, but even routine cautery (applied to stop bleeding) can ignite an inferno. This is a ripe opportunity for innovation!

Ophthalmologists at Brown University developed surgical drapes made of aluminum foil. This flexible material is lightweight, nonflammable, easy to manipulate, sterilizable, and cheaper than disposable paper drapes. Ophthalmologists at Brown used aluminum foil surgical draping in 300 surgical cases and presented their results at the recent Annual Meeting of the Association for Research in Vision and Ophthalmology (ARVO).

The team reported exciting news: no infections, no fires, and no patient-related complications. It appears that a major hospital safety threat can be eliminated.

Will aluminum foil totally replace paper drapes? It's doubtful. Since aluminum is a powerful conductor of electrical current it may not be suitable for some cases when electrical energy is applied, perhaps planned cardioversion following heart surgery. Accidental contact between a live electrical lead and the foil drape could cause serious injury.

More studies will be needed before aluminum foil makes its way into mainstream surgical practice. In the meantime innovators will keep dreaming up ways to build that better mousetrap!

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Technorati Tags: medicine, vision, health and wellness, invention

May 2028: Where Is Your Doctor?

We are beginning to learn more and more about the major health care crunch that is expected to develop in America. Sure, most of us will live longer, healthier lives. The over-85 age group is the fastest growing USA demographic. This 'good news' will create an enormous burden on our already-stretched health care system.

Photo: Salim Fadhley

To make matters worse we will likely not have enough doctors. There are two reasons: an insufficient supply of new physicians and a steady exodus of existing practitioners.

The American Association of Medical Colleges calculates that there is an immediate need for an annual 30% jump in medical school enrollment in order to keep up with the exploding demand for services. This past year the increase was a measly 6% boost. It appears that we will not be able to rely on medical schools to meet the challenges of 2028.

So, what can be done to encourage doctors to keep working? Glad you asked!

According to a recent report published in Forbes, doctors are leaving the profession because they are overworked and underpaid. Many specialists accrue monstrous debt during their training and begin their practices under a dark financial cloud.

Medicare is chopping reimbursements by 15.6% between now and January 2009. That automatically means that other insurers will do likewise. Would you keep working with a 15.6% pay cut?

Let's recap: Overworked, tired, broke, disillusioned. Hey, we didn't mention sued!

Many hardworking physicians cannot afford malpractice insurance. Some surgeons pay over $250,000 a year (if insurance is available at all). Sure, let's identify and deal with unsafe, reckless doctors, but at the same time we need to curtail frivolous malpractice claims. Did you know that only 6% of malpractice claims ever go to trial, and the plaintiff loses 91% of the time.

Bottom line: Over half of practicing physicians discourage their children from becoming doctors.

Twenty years from now I'll be needing cataract surgery and coronary artery bypass surgery. What will you and your family need? There will not be enough experienced medical professionals around in 2028 unless we take action now.

REFERENCE: Reasons Not to Become a Doctor. Forbes 05/05/2008.

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Technorati Tags: doctors, physicians, medicine, health care, medical school, malpractice, vision, health and wellness

Surgeons Given New FDA LASIK Guidelines

On April 24 the FDA's Ophthalmic Devices Panel heard from both satisfied and dissatisfied LASIK patients, as well as representatives from the American Academy of Ophthalmology and the International Society of Refractive Surgery (ISRS) who spoke about the extensive track record of safety and effectiveness for LASIK.

Following a long day of testimony and presentations, the panel has announced several recommendations for consideration by the FDA, including:

• Adding photographic illustrations of certain side effects to the FDA Web site


• Better explanation of certain outcomes, such as myopic patients who have LASIK eventually needing reading glasses post surgery


• More understandable information about the potential risks of LASIK (such as dry eye, halos, glare, starbursts, etc.)


• Clearer explanations of disqualifying conditions that might make a patient a poor candidate for LASIK (such as a family history of keratoconus and a history of depression)


• Additional information or guidance in the labeling about postoperative intraocular pressure


• More detailed guidance for lens implant measurement for post LASIK cataract surgery

Nobody knows if/when such guidelines will become federal regulations. In the meantime it is worthwhile to share these supplemental guidelines with anyone you know who is considering laser refractive surgery.

Adapted from American Academy of Ophthalmology media release, April 28, 2008

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• Experts Advise New Warnings for LASIK
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Technorati Tags: eye surgery, LASIK, FDA, vision